Bruce K. Dixon

SALT LAKE CITY — The unique challenges of providing palliative care to patients with lethal brain tumors can best be met by anticipating and preparing for functional decline and working with a pharmacist and neurologist to optimize the use of steroid and antiseizure medications, according to joint presentations at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Gliomas account for three-quarters of all malignant brain tumors, and half of all gliomas are glioblastomas, which have a 5-year survival rate of 3%, said Dr. Michael E. Salacz, a medical oncologist and board-certified palliative care physician at St. Luke's Cancer Institute in Kansas City, Mo.

Three-quarters of patients with metastatic brain tumors (which outnumber primary brain tumors 10 to 1) die from systemic disease progression and not from brain progression, he explained.

“We're making some preliminary inroads on the treatment of these tumors, but unfortunately what's more common is surgical resection and cancer resurgence,” he said, adding that management of seizures is a crucial part of palliative care in such cases.

“About half of these patients are going to have seizures as their initial presenting symptom, and the other half are going to have seizures sometime during the course of treatment,” Dr. Salacz said.

While traditional antiepileptic drugs such as Dilantin, Depakote, and Tegretol reduce the risk of subsequent seizures, they do not prevent initial seizures, he said, pointing to American Academy of Neurology Guidelines, which state that patients who have not had a seizure after surgery should not be on an antiseizure medication.

“The reality is that over half of physicians use antiepileptic drugs prophylactically. Even though the data show no benefit, many patients will come to palliative care and hospice with seizure prophylaxis. Neurosurgeons have been trained to give Dilantin. As a result, any patient who has had a craniotomy is on Dilantin, and a good portion of these patients are going to have side effects and toxicity as a result of these drugs,” Dr. Salacz said, adding that palliative care doctors treating brain tumor patients who no longer take anything by mouth and have no intravenous line must decide how and whether to give antiepileptic drugs.

“This is a common dilemma in this patient population because the alternative routes of dosing have relatively little data to support them. What I can tell you is that I used transdermal phenobarbital in an advanced patient who would not tolerate oral medications and had a history of seizure disorder,” Dr. Salacz said, adding that after application of the topical paste, the patient was seizure free for his remaining 2 weeks of life.

“While there are no data on use of transdermal phenobarbital, we do know how much of each milligram applied to the skin will get into the bloodstream,” he said.

Short-term corticosteroids, though they have no antitumor effect, can be beneficial at reducing symptoms caused by peritumoral edema.

However, steroids may produce gastrointestinal toxicity, steroid myopathy and, occasionally, lymphopenia or Pneumocystis carinii pneumonia, said Dr. Salacz.

Describing the use of dexamethasone as more art than science, Dr. Salacz said, “There are no magic doses when you're using dexamethasone to reduce brain edema. Oral absorption is rapid and excellent, so you don't need to do [intravenous] steroids when you have an oral rate that you can use.”

Dexamethasone is given every 6 hours, which requires that the patient be awakened at 2 a.m. to take his medication. Dr. Salacz uses a loading dose, though he conceded that doing so is not supported by research data.

“The half-life of dexamethasone is 36–50 hours and pharmacologically it takes about five half-lives for the drug to be out of your system, so the dose I give the patient is going to be gone 7–10 days later,” he said, adding that dexamethasone can be given daily or twice a day.

Steroid-induced insomnia can be minimized by dosing at 8 a.m. and 4 p.m., Dr. Salacz said, adding that neurologic changes follow 1–4 days after a dexamethasone dose change, which can be confusing to a patient on a steroid taper who suddenly develops symptoms.

Cognitive dysfunction occurs in half to three-quarters of brain tumor patients secondary to the disease or to treatment, and has been shown to predict radiographic progression and worse survival.

Although many trials use the Mini-Mental Status Exam (MMSE), Dr. Salacz said that by the time cognitive dysfunction shows up on this screening test, it already has become significant. An alternative is neuropsychiatric testing, which is not widely available or covered by Medicaid. “So I'm stuck trying to help these patients as best as I can out of our clinic,” he said.

Palliative care for brain tumor patients at the end of life also is preventive medicine that involves anticipating and getting the jump on functional decline, said Dr. Christian T. Sinclair, a palliative care and hospice physician.

“Our job is to maximize benefits for the patient and family by discussing alternative services that are available and getting physical or occupational therapy involved early to strengthen the patient as much as possible,” said Dr. Sinclair, with Kansas City Hospice and Palliative Care. Although little can be done to slow functional decline, supplementing a corticosteroid with short-term methyl-phenidate can help increase energy and help cognition, he said.

“Start methylphenidate at 5 mg in the morning and 5 mg at noon. You'll know within a day if it works. If it does, go to 10 mg b.i.d. and top out at 30 mg a day. If the patient gets jittery and anxious, you may want to discontinue the drug,” he said.

Dr. Sinclair's “simple medication regimen at the end of life” was presented as an example: Dexamethasone 4 mg by mouth b.i.d., valproic acid 500 mg by mouth b.i.d., subcutaneous Lovenox daily, morphine ER 15 mg by mouth b.i.d., and morphine 5 mg by mouth every 2 hours p.r.n. for pain. And, he emphasized, some of these doses exceed FDA's normal dosage recommendations, therefore always use the lowest effective dose.

Anticipating functional decline is the goal care for a brain tumor patient at the end of life. DR. SINCLAIR

SALT LAKE CITY — The unique challenges of providing palliative care to patients with lethal brain tumors can best be met by anticipating and preparing for functional decline and working with a pharmacist and neurologist to optimize the use of steroid and antiseizure medications, according to joint presentations at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Gliomas account for three-quarters of all malignant brain tumors, and half of all gliomas are glioblastomas, which have a 5-year survival rate of 3%, said Dr. Michael E. Salacz, a medical oncologist and board-certified palliative care physician at St. Luke's Cancer Institute in Kansas City, Mo.

Three-quarters of patients with metastatic brain tumors (which outnumber primary brain tumors 10 to 1) die from systemic disease progression and not from brain progression, he explained.

“We're making some preliminary inroads on the treatment of these tumors, but unfortunately what's more common is surgical resection and cancer resurgence,” he said, adding that management of seizures is a crucial part of palliative care in such cases.

“About half of these patients are going to have seizures as their initial presenting symptom, and the other half are going to have seizures sometime during the course of treatment,” Dr. Salacz said.

While traditional antiepileptic drugs such as Dilantin, Depakote, and Tegretol reduce the risk of subsequent seizures, they do not prevent initial seizures, he said, pointing to American Academy of Neurology Guidelines, which state that patients who have not had a seizure after surgery should not be on an antiseizure medication.

“The reality is that over half of physicians use antiepileptic drugs prophylactically. Even though the data show no benefit, many patients will come to palliative care and hospice with seizure prophylaxis. Neurosurgeons have been trained to give Dilantin. As a result, any patient who has had a craniotomy is on Dilantin, and a good portion of these patients are going to have side effects and toxicity as a result of these drugs,” Dr. Salacz said, adding that palliative care doctors treating brain tumor patients who no longer take anything by mouth and have no intravenous line must decide how and whether to give antiepileptic drugs.

“This is a common dilemma in this patient population because the alternative routes of dosing have relatively little data to support them. What I can tell you is that I used transdermal phenobarbital in an advanced patient who would not tolerate oral medications and had a history of seizure disorder,” Dr. Salacz said, adding that after application of the topical paste, the patient was seizure free for his remaining 2 weeks of life.

“While there are no data on use of transdermal phenobarbital, we do know how much of each milligram applied to the skin will get into the bloodstream,” he said.

Short-term corticosteroids, though they have no antitumor effect, can be beneficial at reducing symptoms caused by peritumoral edema.

However, steroids may produce gastrointestinal toxicity, steroid myopathy and, occasionally, lymphopenia or Pneumocystis carinii pneumonia, said Dr. Salacz.

Describing the use of dexamethasone as more art than science, Dr. Salacz said, “There are no magic doses when you're using dexamethasone to reduce brain edema. Oral absorption is rapid and excellent, so you don't need to do [intravenous] steroids when you have an oral rate that you can use.”

Dexamethasone is given every 6 hours, which requires that the patient be awakened at 2 a.m. to take his medication. Dr. Salacz uses a loading dose, though he conceded that doing so is not supported by research data.

“The half-life of dexamethasone is 36–50 hours and pharmacologically it takes about five half-lives for the drug to be out of your system, so the dose I give the patient is going to be gone 7–10 days later,” he said, adding that dexamethasone can be given daily or twice a day.

Steroid-induced insomnia can be minimized by dosing at 8 a.m. and 4 p.m., Dr. Salacz said, adding that neurologic changes follow 1–4 days after a dexamethasone dose change, which can be confusing to a patient on a steroid taper who suddenly develops symptoms.

Cognitive dysfunction occurs in half to three-quarters of brain tumor patients secondary to the disease or to treatment, and has been shown to predict radiographic progression and worse survival.

Although many trials use the Mini-Mental Status Exam (MMSE), Dr. Salacz said that by the time cognitive dysfunction shows up on this screening test, it already has become significant. An alternative is neuropsychiatric testing, which is not widely available or covered by Medicaid. “So I'm stuck trying to help these patients as best as I can out of our clinic,” he said.

Palliative care for brain tumor patients at the end of life also is preventive medicine that involves anticipating and getting the jump on functional decline, said Dr. Christian T. Sinclair, a palliative care and hospice physician.

“Our job is to maximize benefits for the patient and family by discussing alternative services that are available and getting physical or occupational therapy involved early to strengthen the patient as much as possible,” said Dr. Sinclair, with Kansas City Hospice and Palliative Care. Although little can be done to slow functional decline, supplementing a corticosteroid with short-term methyl-phenidate can help increase energy and help cognition, he said.

“Start methylphenidate at 5 mg in the morning and 5 mg at noon. You'll know within a day if it works. If it does, go to 10 mg b.i.d. and top out at 30 mg a day. If the patient gets jittery and anxious, you may want to discontinue the drug,” he said.

Dr. Sinclair's “simple medication regimen at the end of life” was presented as an example: Dexamethasone 4 mg by mouth b.i.d., valproic acid 500 mg by mouth b.i.d., subcutaneous Lovenox daily, morphine ER 15 mg by mouth b.i.d., and morphine 5 mg by mouth every 2 hours p.r.n. for pain. And, he emphasized, some of these doses exceed FDA's normal dosage recommendations, therefore always use the lowest effective dose.

Anticipating functional decline is the goal care for a brain tumor patient at the end of life. DR. SINCLAIR

SALT LAKE CITY — The unique challenges of providing palliative care to patients with lethal brain tumors can best be met by anticipating and preparing for functional decline and working with a pharmacist and neurologist to optimize the use of steroid and antiseizure medications, according to joint presentations at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Gliomas account for three-quarters of all malignant brain tumors, and half of all gliomas are glioblastomas, which have a 5-year survival rate of 3%, said Dr. Michael E. Salacz, a medical oncologist and board-certified palliative care physician at St. Luke's Cancer Institute in Kansas City, Mo.

Three-quarters of patients with metastatic brain tumors (which outnumber primary brain tumors 10 to 1) die from systemic disease progression and not from brain progression, he explained.

“We're making some preliminary inroads on the treatment of these tumors, but unfortunately what's more common is surgical resection and cancer resurgence,” he said, adding that management of seizures is a crucial part of palliative care in such cases.

“About half of these patients are going to have seizures as their initial presenting symptom, and the other half are going to have seizures sometime during the course of treatment,” Dr. Salacz said.

While traditional antiepileptic drugs such as Dilantin, Depakote, and Tegretol reduce the risk of subsequent seizures, they do not prevent initial seizures, he said, pointing to American Academy of Neurology Guidelines, which state that patients who have not had a seizure after surgery should not be on an antiseizure medication.

“The reality is that over half of physicians use antiepileptic drugs prophylactically. Even though the data show no benefit, many patients will come to palliative care and hospice with seizure prophylaxis. Neurosurgeons have been trained to give Dilantin. As a result, any patient who has had a craniotomy is on Dilantin, and a good portion of these patients are going to have side effects and toxicity as a result of these drugs,” Dr. Salacz said, adding that palliative care doctors treating brain tumor patients who no longer take anything by mouth and have no intravenous line must decide how and whether to give antiepileptic drugs.

“This is a common dilemma in this patient population because the alternative routes of dosing have relatively little data to support them. What I can tell you is that I used transdermal phenobarbital in an advanced patient who would not tolerate oral medications and had a history of seizure disorder,” Dr. Salacz said, adding that after application of the topical paste, the patient was seizure free for his remaining 2 weeks of life.

“While there are no data on use of transdermal phenobarbital, we do know how much of each milligram applied to the skin will get into the bloodstream,” he said.

Short-term corticosteroids, though they have no antitumor effect, can be beneficial at reducing symptoms caused by peritumoral edema.

However, steroids may produce gastrointestinal toxicity, steroid myopathy and, occasionally, lymphopenia or Pneumocystis carinii pneumonia, said Dr. Salacz.

Describing the use of dexamethasone as more art than science, Dr. Salacz said, “There are no magic doses when you're using dexamethasone to reduce brain edema. Oral absorption is rapid and excellent, so you don't need to do [intravenous] steroids when you have an oral rate that you can use.”

Dexamethasone is given every 6 hours, which requires that the patient be awakened at 2 a.m. to take his medication. Dr. Salacz uses a loading dose, though he conceded that doing so is not supported by research data.

“The half-life of dexamethasone is 36–50 hours and pharmacologically it takes about five half-lives for the drug to be out of your system, so the dose I give the patient is going to be gone 7–10 days later,” he said, adding that dexamethasone can be given daily or twice a day.

Steroid-induced insomnia can be minimized by dosing at 8 a.m. and 4 p.m., Dr. Salacz said, adding that neurologic changes follow 1–4 days after a dexamethasone dose change, which can be confusing to a patient on a steroid taper who suddenly develops symptoms.

Cognitive dysfunction occurs in half to three-quarters of brain tumor patients secondary to the disease or to treatment, and has been shown to predict radiographic progression and worse survival.

Although many trials use the Mini-Mental Status Exam (MMSE), Dr. Salacz said that by the time cognitive dysfunction shows up on this screening test, it already has become significant. An alternative is neuropsychiatric testing, which is not widely available or covered by Medicaid. “So I'm stuck trying to help these patients as best as I can out of our clinic,” he said.

Palliative care for brain tumor patients at the end of life also is preventive medicine that involves anticipating and getting the jump on functional decline, said Dr. Christian T. Sinclair, a palliative care and hospice physician.

“Our job is to maximize benefits for the patient and family by discussing alternative services that are available and getting physical or occupational therapy involved early to strengthen the patient as much as possible,” said Dr. Sinclair, with Kansas City Hospice and Palliative Care. Although little can be done to slow functional decline, supplementing a corticosteroid with short-term methyl-phenidate can help increase energy and help cognition, he said.

“Start methylphenidate at 5 mg in the morning and 5 mg at noon. You'll know within a day if it works. If it does, go to 10 mg b.i.d. and top out at 30 mg a day. If the patient gets jittery and anxious, you may want to discontinue the drug,” he said.

Dr. Sinclair's “simple medication regimen at the end of life” was presented as an example: Dexamethasone 4 mg by mouth b.i.d., valproic acid 500 mg by mouth b.i.d., subcutaneous Lovenox daily, morphine ER 15 mg by mouth b.i.d., and morphine 5 mg by mouth every 2 hours p.r.n. for pain. And, he emphasized, some of these doses exceed FDA's normal dosage recommendations, therefore always use the lowest effective dose.

Anticipating functional decline is the goal care for a brain tumor patient at the end of life. DR. SINCLAIR

INDIANAPOLIS – Adolescent women at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk women aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the woman and the man she was involved with, as well as by sexual interest and mood, Dr. Ott explained, adding that this challenges the popular notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort of young women completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the women had an active STI.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days.

“Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” Dr. Ott said.

With regard to interpersonal influences, each unit increase in partner support raised the hazard of having sex by 25%, and each unit increase in relationship quality raised the hazard by 5%.

A recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%, she said.

INDIANAPOLIS – Adolescent women at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk women aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the woman and the man she was involved with, as well as by sexual interest and mood, Dr. Ott explained, adding that this challenges the popular notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort of young women completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the women had an active STI.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days.

“Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” Dr. Ott said.

With regard to interpersonal influences, each unit increase in partner support raised the hazard of having sex by 25%, and each unit increase in relationship quality raised the hazard by 5%.

A recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%, she said.

INDIANAPOLIS – Adolescent women at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk women aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the woman and the man she was involved with, as well as by sexual interest and mood, Dr. Ott explained, adding that this challenges the popular notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort of young women completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the women had an active STI.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days.

“Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” Dr. Ott said.

With regard to interpersonal influences, each unit increase in partner support raised the hazard of having sex by 25%, and each unit increase in relationship quality raised the hazard by 5%.

A recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%, she said.

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

"This is a very cost-effective alternative for anyone who doesn't have an EMR system," said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

"I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine," said Dr. Lucas, who puts one label into the patient's chart and gives a signed copy to the patient for the pharmacy. "Or I stick the label or labels on a sheet of paper and fax it to the pharmacy."

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing "Statin 20 mg #90," the label also says "cholesterol med."

"Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote," said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The labeling system also integrates with software programs like Outlook and Quickbooks to make individual labels. "It's nice because it has an optional mailing bar code to facilitate mailing," she added.

Pharmacists like being able to read the prescriptions without having to call and ask me what I wrote. DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

"This is a very cost-effective alternative for anyone who doesn't have an EMR system," said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

"I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine," said Dr. Lucas, who puts one label into the patient's chart and gives a signed copy to the patient for the pharmacy. "Or I stick the label or labels on a sheet of paper and fax it to the pharmacy."

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing "Statin 20 mg #90," the label also says "cholesterol med."

"Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote," said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The labeling system also integrates with software programs like Outlook and Quickbooks to make individual labels. "It's nice because it has an optional mailing bar code to facilitate mailing," she added.

Pharmacists like being able to read the prescriptions without having to call and ask me what I wrote. DR. LUCAS

If you're not ready to invest thousands of dollars in an electronic medical records system, a desktop label writer may be just what the doctor ordered.

"This is a very cost-effective alternative for anyone who doesn't have an EMR system," said Dr. Stephanie Lucas, who equipped her two-physician Detroit practice with several Dymo Twin Turbo label makers at a cost of about $150 apiece.

"I have all my prescriptions on the attached software, so all I have to do to print a label is go to the list on my computer, click on the prescription, and it comes out of the machine," said Dr. Lucas, who puts one label into the patient's chart and gives a signed copy to the patient for the pharmacy. "Or I stick the label or labels on a sheet of paper and fax it to the pharmacy."

The internist and endocrinologist take an extra step to ensure that patients know what their medications are for. For example, in addition to printing "Statin 20 mg #90," the label also says "cholesterol med."

"Patients love it, and pharmacists appreciate being able to read the prescriptions without ever having to call and ask me what I wrote," said Dr. Lucas, whose bad handwriting in grammar school drew a few knuckle raps from a ruler-wielding teacher.

The labeling system also integrates with software programs like Outlook and Quickbooks to make individual labels. "It's nice because it has an optional mailing bar code to facilitate mailing," she added.

Pharmacists like being able to read the prescriptions without having to call and ask me what I wrote. DR. LUCAS

SALT LAKE CITY — The new subspecialty of hospice and palliative medicine will be open to osteopathic as well as allopathic physicians, following a decision by the American Osteopathic Association's Bureau of Osteopathic Specialists to approve certification in the discipline.

The Feb. 16 action complements a decision by the American Board of Medical Specialties last September to move forward with plans to allow allopathic physicians to become certified in the new subspecialty.

ABMS-recognized certification will be offered to physicians in 10 specialties: obstetrics and gynecology, family medicine, internal medicine, anesthesiology, emergency medicine, pediatrics, physical medicine and rehabilitation, psychiatry and neurology, radiology, and surgery.

Osteopathic certification in the new field will be offered to osteopathic physicians in four specialties: family medicine, internal medicine, neurology and psychiatry, and physical medicine and rehabilitation.

Sponsorship of a subspecialty by such a large number of specialty boards is unprecedented, according to Dale E. Lupu, Ph.D., chief executive officer of the American Board of Hospice and Palliative Medicine (ABHPM), headquartered in Silver Spring, Md.

“Having 10 specialties working together is completely new,” she said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

It took the ABHPM 10 years to persuade the ABMS to recognize hospice and palliative medicine as a medical subspecialty, Dr. Lupu said. From 1996 through 2006, the ABHPM certified more than 2,800 physicians in hospice and palliative medicine, she added.

The effort to achieve ABMS-recognized subspecialty status also involves accreditation of graduate medical education by the Accreditation Council of Graduate Medical Education (ACGME). “Successful completion of an accredited educational program usually is a prerequisite to admission to an ABMS board examination,” Dr. Lupu noted.

Starting in 2008, a new certification exam will be available, administered by the cosponsoring ABMS member boards.

During a 5-year grandfather period (2008–2012), physicians from the 10 ABMS specialties can sit for the board exam in hospice and palliative medicine without completing fellowship training, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

During this period, applicants must qualify for the exam by having cared for at least 50 terminally ill patients and by meeting other criteria. (Eligibility requirements can be viewed at www.abhpm.orgwww.aahpm.org

After the initial 5-year period, “it will be necessary for [applicants] to take a year-long fellowship training before they can sit for the board and be certified in hospice and palliative medicine,” Dr. Schonwetter, a former chairman of the ABHPM, said in an interview.

There's much work to be done, he added. “We need to expand our services among hospitals, nursing homes, and assisted-living facilities, and to educate and understand the needs of physicians from the multiple disciplines” who wish to become palliative care specialists.

“Approval of hospice and palliative medicine by 10 ABMS specialties shows the desire for this type of care by our colleagues, who see on a first-hand basis what hospice and palliative medicine can do for their patients,” he said.

SALT LAKE CITY — The new subspecialty of hospice and palliative medicine will be open to osteopathic as well as allopathic physicians, following a decision by the American Osteopathic Association's Bureau of Osteopathic Specialists to approve certification in the discipline.

The Feb. 16 action complements a decision by the American Board of Medical Specialties last September to move forward with plans to allow allopathic physicians to become certified in the new subspecialty.

ABMS-recognized certification will be offered to physicians in 10 specialties: obstetrics and gynecology, family medicine, internal medicine, anesthesiology, emergency medicine, pediatrics, physical medicine and rehabilitation, psychiatry and neurology, radiology, and surgery.

Osteopathic certification in the new field will be offered to osteopathic physicians in four specialties: family medicine, internal medicine, neurology and psychiatry, and physical medicine and rehabilitation.

Sponsorship of a subspecialty by such a large number of specialty boards is unprecedented, according to Dale E. Lupu, Ph.D., chief executive officer of the American Board of Hospice and Palliative Medicine (ABHPM), headquartered in Silver Spring, Md.

“Having 10 specialties working together is completely new,” she said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

It took the ABHPM 10 years to persuade the ABMS to recognize hospice and palliative medicine as a medical subspecialty, Dr. Lupu said. From 1996 through 2006, the ABHPM certified more than 2,800 physicians in hospice and palliative medicine, she added.

The effort to achieve ABMS-recognized subspecialty status also involves accreditation of graduate medical education by the Accreditation Council of Graduate Medical Education (ACGME). “Successful completion of an accredited educational program usually is a prerequisite to admission to an ABMS board examination,” Dr. Lupu noted.

Starting in 2008, a new certification exam will be available, administered by the cosponsoring ABMS member boards.

During a 5-year grandfather period (2008–2012), physicians from the 10 ABMS specialties can sit for the board exam in hospice and palliative medicine without completing fellowship training, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

During this period, applicants must qualify for the exam by having cared for at least 50 terminally ill patients and by meeting other criteria. (Eligibility requirements can be viewed at www.abhpm.orgwww.aahpm.org

After the initial 5-year period, “it will be necessary for [applicants] to take a year-long fellowship training before they can sit for the board and be certified in hospice and palliative medicine,” Dr. Schonwetter, a former chairman of the ABHPM, said in an interview.

There's much work to be done, he added. “We need to expand our services among hospitals, nursing homes, and assisted-living facilities, and to educate and understand the needs of physicians from the multiple disciplines” who wish to become palliative care specialists.

“Approval of hospice and palliative medicine by 10 ABMS specialties shows the desire for this type of care by our colleagues, who see on a first-hand basis what hospice and palliative medicine can do for their patients,” he said.

SALT LAKE CITY — The new subspecialty of hospice and palliative medicine will be open to osteopathic as well as allopathic physicians, following a decision by the American Osteopathic Association's Bureau of Osteopathic Specialists to approve certification in the discipline.

The Feb. 16 action complements a decision by the American Board of Medical Specialties last September to move forward with plans to allow allopathic physicians to become certified in the new subspecialty.

ABMS-recognized certification will be offered to physicians in 10 specialties: obstetrics and gynecology, family medicine, internal medicine, anesthesiology, emergency medicine, pediatrics, physical medicine and rehabilitation, psychiatry and neurology, radiology, and surgery.

Osteopathic certification in the new field will be offered to osteopathic physicians in four specialties: family medicine, internal medicine, neurology and psychiatry, and physical medicine and rehabilitation.

Sponsorship of a subspecialty by such a large number of specialty boards is unprecedented, according to Dale E. Lupu, Ph.D., chief executive officer of the American Board of Hospice and Palliative Medicine (ABHPM), headquartered in Silver Spring, Md.

“Having 10 specialties working together is completely new,” she said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

It took the ABHPM 10 years to persuade the ABMS to recognize hospice and palliative medicine as a medical subspecialty, Dr. Lupu said. From 1996 through 2006, the ABHPM certified more than 2,800 physicians in hospice and palliative medicine, she added.

The effort to achieve ABMS-recognized subspecialty status also involves accreditation of graduate medical education by the Accreditation Council of Graduate Medical Education (ACGME). “Successful completion of an accredited educational program usually is a prerequisite to admission to an ABMS board examination,” Dr. Lupu noted.

Starting in 2008, a new certification exam will be available, administered by the cosponsoring ABMS member boards.

During a 5-year grandfather period (2008–2012), physicians from the 10 ABMS specialties can sit for the board exam in hospice and palliative medicine without completing fellowship training, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

During this period, applicants must qualify for the exam by having cared for at least 50 terminally ill patients and by meeting other criteria. (Eligibility requirements can be viewed at www.abhpm.orgwww.aahpm.org

After the initial 5-year period, “it will be necessary for [applicants] to take a year-long fellowship training before they can sit for the board and be certified in hospice and palliative medicine,” Dr. Schonwetter, a former chairman of the ABHPM, said in an interview.

There's much work to be done, he added. “We need to expand our services among hospitals, nursing homes, and assisted-living facilities, and to educate and understand the needs of physicians from the multiple disciplines” who wish to become palliative care specialists.

“Approval of hospice and palliative medicine by 10 ABMS specialties shows the desire for this type of care by our colleagues, who see on a first-hand basis what hospice and palliative medicine can do for their patients,” he said.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices.

Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project (NCP) for Quality Palliative Care.

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said NCP chair Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer bereavement support for the family.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, Dr. Schonwetter said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained the internist, who is the immediate past president of the American Academy of Hospice and Palliative Medicine.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices.

Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project (NCP) for Quality Palliative Care.

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said NCP chair Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer bereavement support for the family.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, Dr. Schonwetter said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained the internist, who is the immediate past president of the American Academy of Hospice and Palliative Medicine.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices.

Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project (NCP) for Quality Palliative Care.

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said NCP chair Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer bereavement support for the family.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, Dr. Schonwetter said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained the internist, who is the immediate past president of the American Academy of Hospice and Palliative Medicine.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices. Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project for Quality Palliative Care (NCP).

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, NCP chair Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer families bereavement support.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, he said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained Dr. Schonwetter, who is an internist and the immediate past president of the American Academy of Hospice and Palliative Medicine.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices. Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project for Quality Palliative Care (NCP).

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, NCP chair Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer families bereavement support.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, he said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained Dr. Schonwetter, who is an internist and the immediate past president of the American Academy of Hospice and Palliative Medicine.

The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices. Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project for Quality Palliative Care (NCP).

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, NCP chair Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer families bereavement support.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, he said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained Dr. Schonwetter, who is an internist and the immediate past president of the American Academy of Hospice and Palliative Medicine.

INDIANAPOLIS — Female adolescents at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians and other counselors should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk females aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the girl and the male she was involved with, as well as by sexual interest and mood, Dr. Ott explained. This challenges the notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the girls had an active STI, either Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis.

Frailty models were used to estimate the effects of intrapersonal and interpersonal factors, as well as the effect of STI diagnosis, on the time to ending a period of abstinence. A frailty model is an adaptation of a proportional hazards model that controls for multiple observations from a single participant.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days. “Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” she said.

As for interpersonal influences, each unit increase in partner support hiked the hazard of having sex by 25%; each unit increase in relationship quality raised the hazard by 5%, while a recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%.

However, although mood and the influence of a previous STI lowered the risk of ending short periods of abstinence, they had little effect on ending longer periods of abstinence.

The longer that young women at high risk for STIs went without having sex, the more likely they were to remain abstinent, Dr. Ott said.

INDIANAPOLIS — Female adolescents at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians and other counselors should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk females aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the girl and the male she was involved with, as well as by sexual interest and mood, Dr. Ott explained. This challenges the notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the girls had an active STI, either Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis.

Frailty models were used to estimate the effects of intrapersonal and interpersonal factors, as well as the effect of STI diagnosis, on the time to ending a period of abstinence. A frailty model is an adaptation of a proportional hazards model that controls for multiple observations from a single participant.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days. “Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” she said.

As for interpersonal influences, each unit increase in partner support hiked the hazard of having sex by 25%; each unit increase in relationship quality raised the hazard by 5%, while a recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%.

However, although mood and the influence of a previous STI lowered the risk of ending short periods of abstinence, they had little effect on ending longer periods of abstinence.

The longer that young women at high risk for STIs went without having sex, the more likely they were to remain abstinent, Dr. Ott said.

INDIANAPOLIS — Female adolescents at high risk for acquiring sexually transmitted infections may not respond well to counseling and prevention efforts that focus on the fear of becoming infected, according to a study by researchers at Indiana University in Indianapolis.

Instead, programs and physicians may need to tailor their pregnancy and sexually transmitted infection (STI) counseling to recent patterns of sexual behavior, said Dr. Mary A. Ott of the university's section of adolescent medicine.

“Physicians and other counselors should be aware that fear related to being infected influences sexual behavior only in the short term, and therefore should focus on interpersonal and relationship factors to influence long-term decisions about sex and abstinence,” Dr. Ott said at the annual meeting of the Midwest Society for Pediatric Research.

This urban study of 378 high-risk females aged 14–18 years indicated that the decision to have sex after a period of abstinence was strongly influenced by the relationship between the girl and the male she was involved with, as well as by sexual interest and mood, Dr. Ott explained. This challenges the notion that adolescent sex is largely casual and lacking in personal commitment and caring.

The cohort completed quarterly face-to-face interviews and two 3-month daily diary collections per year, and were followed up for a maximum of 4.5 years.

Periods of abstinence were defined as consecutive days of no vaginal sex as recorded in the daily diary. At the time of the study, 9% of the girls had an active STI, either Chlamydia trachomatis, Neisseria gonorrhea, or Trichomonas vaginalis.

Frailty models were used to estimate the effects of intrapersonal and interpersonal factors, as well as the effect of STI diagnosis, on the time to ending a period of abstinence. A frailty model is an adaptation of a proportional hazards model that controls for multiple observations from a single participant.

The study cohort had more than 6,000 periods of abstinence, of which 55% ended in sex. The median length of abstinence was 10 days, and the mean length was 39 days. “Each year increase in a participant's age increased the hazard of ending an abstinence period with sex by 22%,” Dr. Ott said.

“For interpersonal influences, each unit increase in positive mood increased the hazard by 2%, each unit increase in negative mood decreased the hazard by 1%, and each unit increase in sexual interest raised the hazard by 22%,” she said.

As for interpersonal influences, each unit increase in partner support hiked the hazard of having sex by 25%; each unit increase in relationship quality raised the hazard by 5%, while a recent STI decreased the hazard of having sex and stopping a period of abstinence by 17%.

However, although mood and the influence of a previous STI lowered the risk of ending short periods of abstinence, they had little effect on ending longer periods of abstinence.

The longer that young women at high risk for STIs went without having sex, the more likely they were to remain abstinent, Dr. Ott said.

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said. In the meantime, the RUC discussions remain confidential.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, who is a medical oncologist in Atlanta.

“There's no doubt that primary care interests—family physicians and geriatricians in particular—are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

“It's not that the relative value system is screwed up or that CMS is made up of bad people,” Dr. Lichtenfeld added. “The problem is there's not enough money being appropriated by Congress, there's no new money coming in, and primary care gets beat up pretty badly as a result of that.”

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society (AGS), noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications. “These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility.”

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

The relatively small number of geriatricians in the United States—7,000 out of a total physician population of 650,000—is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

About 45 U.S. medical schools offer significant geriatrics curricula, he added, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

ELSEVIER GLOBAL MEDICAL NEWS

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said. In the meantime, the RUC discussions remain confidential.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, who is a medical oncologist in Atlanta.

“There's no doubt that primary care interests—family physicians and geriatricians in particular—are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

“It's not that the relative value system is screwed up or that CMS is made up of bad people,” Dr. Lichtenfeld added. “The problem is there's not enough money being appropriated by Congress, there's no new money coming in, and primary care gets beat up pretty badly as a result of that.”

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society (AGS), noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications. “These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility.”

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

The relatively small number of geriatricians in the United States—7,000 out of a total physician population of 650,000—is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

About 45 U.S. medical schools offer significant geriatrics curricula, he added, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

ELSEVIER GLOBAL MEDICAL NEWS

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said. In the meantime, the RUC discussions remain confidential.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, who is a medical oncologist in Atlanta.

“There's no doubt that primary care interests—family physicians and geriatricians in particular—are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

“It's not that the relative value system is screwed up or that CMS is made up of bad people,” Dr. Lichtenfeld added. “The problem is there's not enough money being appropriated by Congress, there's no new money coming in, and primary care gets beat up pretty badly as a result of that.”

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society (AGS), noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications. “These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility.”

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

The relatively small number of geriatricians in the United States—7,000 out of a total physician population of 650,000—is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

About 45 U.S. medical schools offer significant geriatrics curricula, he added, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — MRI findings within 12 weeks of serious low back pain inception are unlikely to represent new structural change, according to a study at Stanford (Calif.) University.

“We had hypothesized that serious low back pain episodes would be commonly associated with new and specific findings on MRI, and we were really thinking about such things as annular tears, fissures, disk herniation, new disk protrusion, and end plate changes. But … the data didn't support that hypothesis,” said Dr. Eugene Carragee, professor of orthopedic surgery, at the annual meeting of the North American Spine Society.

The findings emerged from a 5-year, prospective, observational study with baseline and post-low back pain monitoring of 200 subjects with lifetime histories free of significant low back pain problems but who were at high risk for new low back pain episodes, Dr. Carragee said.

At baseline, patients underwent physical examinations, plain radiographs, and MRIs; they were then followed for 5 years and participated in a detailed telephone interview every 6 months. Those with a new severe low back pain episode were assessed with diagnostic tests. New MRIs, taken within 6–12 weeks of the start of a new low back pain episode, were then compared with baseline (asymptomatic) images.

Within the total cohort, 25% were evaluated with a lumbar MRI for clinically serious low back pain episodes occurring during follow-up, and 6% had a primary radicular complaint. Of those 51 patients, 43 either had an unchanged MRI or showed regression of baseline changes.

“There are relatively few new findings compared to the burden of disease at baseline. That is, when you put the scan up and you see 5 or 10 things—an annular fissure or perhaps some facet arthrosis—the overwhelming amount of those things were there years before,” Dr. Carragee said.

The most common progressive findings were disk signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two patients, both with primary radicular complaints, had new findings of probable clinical significance.

“Both had primary leg pain and one had a new disk extrusion with root compression but no trauma. The other had some degenerative disease at the L4–5 level and, at follow-up scan, had a grade 1 spondylolisthesis with increased stenosis,” Dr. Carragee said.

Subjects involved in current compensation claims were more likely to have an MRI scan to evaluate a low back pain episode but were unlikely to have significant new findings.

“In usual practice, if a patient has minor trauma from a fender bender or a fall and you get an MRI, it shows a high-intensity zone, an annular fissure, or end plate changes, and the normal thing that we think is that these findings are … attributed to an acute event and are related to the symptoms, but that's not what we found,” he said, adding that fewer than 1 in 12 annular fissures and 1 in 15 disk protrusions found on scans were new.

“In acute low back pain, MRI findings within 12 weeks of events were highly unlikely to represent new structural changes to the spine, and this means [physicians] directing treatment need to be careful before saying, 'Aha! I found the cause'” of a patient's low back pain, Dr. Carragee concluded.

'Physicians directing treatment need to be careful before saying, “Aha! I found the cause.”' DR. CARRAGEE

SEATTLE — MRI findings within 12 weeks of serious low back pain inception are unlikely to represent new structural change, according to a study at Stanford (Calif.) University.

“We had hypothesized that serious low back pain episodes would be commonly associated with new and specific findings on MRI, and we were really thinking about such things as annular tears, fissures, disk herniation, new disk protrusion, and end plate changes. But … the data didn't support that hypothesis,” said Dr. Eugene Carragee, professor of orthopedic surgery, at the annual meeting of the North American Spine Society.

The findings emerged from a 5-year, prospective, observational study with baseline and post-low back pain monitoring of 200 subjects with lifetime histories free of significant low back pain problems but who were at high risk for new low back pain episodes, Dr. Carragee said.

At baseline, patients underwent physical examinations, plain radiographs, and MRIs; they were then followed for 5 years and participated in a detailed telephone interview every 6 months. Those with a new severe low back pain episode were assessed with diagnostic tests. New MRIs, taken within 6–12 weeks of the start of a new low back pain episode, were then compared with baseline (asymptomatic) images.

Within the total cohort, 25% were evaluated with a lumbar MRI for clinically serious low back pain episodes occurring during follow-up, and 6% had a primary radicular complaint. Of those 51 patients, 43 either had an unchanged MRI or showed regression of baseline changes.

“There are relatively few new findings compared to the burden of disease at baseline. That is, when you put the scan up and you see 5 or 10 things—an annular fissure or perhaps some facet arthrosis—the overwhelming amount of those things were there years before,” Dr. Carragee said.

The most common progressive findings were disk signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two patients, both with primary radicular complaints, had new findings of probable clinical significance.

“Both had primary leg pain and one had a new disk extrusion with root compression but no trauma. The other had some degenerative disease at the L4–5 level and, at follow-up scan, had a grade 1 spondylolisthesis with increased stenosis,” Dr. Carragee said.

Subjects involved in current compensation claims were more likely to have an MRI scan to evaluate a low back pain episode but were unlikely to have significant new findings.

“In usual practice, if a patient has minor trauma from a fender bender or a fall and you get an MRI, it shows a high-intensity zone, an annular fissure, or end plate changes, and the normal thing that we think is that these findings are … attributed to an acute event and are related to the symptoms, but that's not what we found,” he said, adding that fewer than 1 in 12 annular fissures and 1 in 15 disk protrusions found on scans were new.

“In acute low back pain, MRI findings within 12 weeks of events were highly unlikely to represent new structural changes to the spine, and this means [physicians] directing treatment need to be careful before saying, 'Aha! I found the cause'” of a patient's low back pain, Dr. Carragee concluded.

'Physicians directing treatment need to be careful before saying, “Aha! I found the cause.”' DR. CARRAGEE

SEATTLE — MRI findings within 12 weeks of serious low back pain inception are unlikely to represent new structural change, according to a study at Stanford (Calif.) University.

“We had hypothesized that serious low back pain episodes would be commonly associated with new and specific findings on MRI, and we were really thinking about such things as annular tears, fissures, disk herniation, new disk protrusion, and end plate changes. But … the data didn't support that hypothesis,” said Dr. Eugene Carragee, professor of orthopedic surgery, at the annual meeting of the North American Spine Society.

The findings emerged from a 5-year, prospective, observational study with baseline and post-low back pain monitoring of 200 subjects with lifetime histories free of significant low back pain problems but who were at high risk for new low back pain episodes, Dr. Carragee said.

At baseline, patients underwent physical examinations, plain radiographs, and MRIs; they were then followed for 5 years and participated in a detailed telephone interview every 6 months. Those with a new severe low back pain episode were assessed with diagnostic tests. New MRIs, taken within 6–12 weeks of the start of a new low back pain episode, were then compared with baseline (asymptomatic) images.

Within the total cohort, 25% were evaluated with a lumbar MRI for clinically serious low back pain episodes occurring during follow-up, and 6% had a primary radicular complaint. Of those 51 patients, 43 either had an unchanged MRI or showed regression of baseline changes.

“There are relatively few new findings compared to the burden of disease at baseline. That is, when you put the scan up and you see 5 or 10 things—an annular fissure or perhaps some facet arthrosis—the overwhelming amount of those things were there years before,” Dr. Carragee said.

The most common progressive findings were disk signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two patients, both with primary radicular complaints, had new findings of probable clinical significance.

“Both had primary leg pain and one had a new disk extrusion with root compression but no trauma. The other had some degenerative disease at the L4–5 level and, at follow-up scan, had a grade 1 spondylolisthesis with increased stenosis,” Dr. Carragee said.

Subjects involved in current compensation claims were more likely to have an MRI scan to evaluate a low back pain episode but were unlikely to have significant new findings.

“In usual practice, if a patient has minor trauma from a fender bender or a fall and you get an MRI, it shows a high-intensity zone, an annular fissure, or end plate changes, and the normal thing that we think is that these findings are … attributed to an acute event and are related to the symptoms, but that's not what we found,” he said, adding that fewer than 1 in 12 annular fissures and 1 in 15 disk protrusions found on scans were new.

“In acute low back pain, MRI findings within 12 weeks of events were highly unlikely to represent new structural changes to the spine, and this means [physicians] directing treatment need to be careful before saying, 'Aha! I found the cause'” of a patient's low back pain, Dr. Carragee concluded.

'Physicians directing treatment need to be careful before saying, “Aha! I found the cause.”' DR. CARRAGEE

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

ELSEVIER GLOBAL MEDICAL NEWS

Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

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Improved reimbursement remains the focus of efforts to shore up the nation's supply of geriatricians.

Medicare's physician fee schedule for nursing home care urgently needs to be adjusted to reflect the real costs of diagnosis and treatment, according to Dr. Steven A. Levenson, president of the American Medical Directors Association (AMDA).

Without such a change, the number of physicians with geriatric competence will continue to decline, and elderly patients will be subjected to increasingly substandard care, Dr. Levenson predicted.

In early February, AMDA went before the American Medical Association's Resource-Based Relative Value Scale Update Committee (RUC) meeting in San Diego with suggested adjustments to nursing home CPT codes (99304–99310 and 99318) that would increase Medicare reimbursement for new admissions, subsequent visits, and annual visits by physicians.

A 5-year fee-schedule review, which began in 2003, was largely completed last year. But certain code families, including nursing home codes, were not submitted for review until the February RUC meeting.

“At this meeting, we asked that the codes reflect the care of nursing home and postacute patients, and we presented information based on surveys of our members,” Dr. Levenson said in an interview.

“The challenge was to get physicians representing certain other specialties who don't work in this environment to understand that the geriatric population has changed, and that these patients pose a real diagnostic and management challenge,” said Dr. Levenson, a consulting geriatrician in Towson, Md., who is a medical director of five Maryland facilities owned by Genesis Health Care, which operates more than 200 nursing centers and assisted-living communities in 13 eastern states.

The AMA formed the RUC in 1992 to act as an expert panel in developing relative-value recommendations to the Centers for Medicare and Medicaid Services (CMS). The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies, from anesthesiology to urology.

Although the RUC makes recommendations only for Medicare fees, it influences nearly all health insurers because most base their fees and reimbursement rates on the Medicare fee schedule, said Dr. Len Lichtenfeld, the American College of Physicians' representative on the committee.

A final decision about the reimbursement proposal won't be made before midsummer, pending review by CMS and a public comment period, he said.

Reimbursement rates lie at the heart of the much-discussed shortage of physicians trained in geriatrics, said Dr. Lichtenfeld, a medical oncologist in Atlanta.

“There's no doubt that primary care interests–family physicians and geriatricians in particular–are sorely lagging other specialties when it comes to [Medicare] reimbursement income. Taking care of nursing home patients is a labor of love,” he said.

Dr. Sharon Brangman, a member of the board of directors of the American Geriatrics Society, noted that physicians often shy away from geriatric patients because of the complex nature of their illnesses and medications.

“These patients often have complicated social and psychiatric issues and doctors have a limited amount of time they can spend on a given person,” said Dr. Brangman, who is professor of geriatric medicine at the State University of New York, Syracuse.

Dr. Arthur Altbuch, a geriatrician in Janesville, Wis., sees nursing home patients, mostly on his own time. “Let's look at the reimbursement rate for a routine visit to a stable nursing home resident, and you are reviewing his weight, vital signs, medications, and basically everything is okay. In Wisconsin, that pays $30.76 under code 99307, and that doesn't include driving back and forth to the nursing facility,” he noted.

Increasingly, physicians won't provide care at nursing homes unless they have enough resident patients to make their time there worthwhile, said Dr. Altbuch, director of the family medicine residency program for Mercy Health System, which spans much of Southern Wisconsin and Northern Illinois.

“Mercy Health System employs about 200 doctors, and I am one of only two geriatricians, and therefore I cannot refuse geriatric patients, so I take my lumps,” he added.

The economics of the problem extend beyond Medicare reimbursement. “The average medical student has $100,000 worth of debt by the time he graduates, so to enter a procedural specialty that offers higher pay becomes extremely attractive,” said Dr. Robert Butler, president and CEO of the International Longevity Center in New York City.

The relatively small number of geriatricians in the United States–7,000 out of a total physician population of 650,000–is primarily the result of reimbursement issues and the increasing complexity of managing the health of aging patients, but the shortage is aggravated by the junior position of geriatrics in most medical schools, Dr. Butler said an interview.

About 45 of the 144 U.S. medical schools offer significant geriatrics curricula, he noted, but “just because they have a program doesn't mean they require students to go through it.”

Dr. Levenson sees that as a growing problem, because thousands of physicians who are providing care to geriatric patients “really don't know what they're doing … and create problems that have to be cleaned up by someone else.”

On the political front, physicians cannot just wait for events to unfold, Dr. Lichtenfeld said. “They need to step up to the plate and complete these surveys [about reimbursement], or we're dead in the water.”

Nor can physicians expect help from the patients themselves, Dr. Altbuch noted. “Nursing home patients don't vote and they have no political clout, and politicians know this.”

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