Timothy F. Kirn

SACRAMENTO – Another medical school has joined what could be a growing movement to ban faculty and residents from accepting gifts from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors. “We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other schools were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. Thus, the 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article noted that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines. But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors said. They noted that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item. At the UC Davis Cancer Center alone, it is estimated that companies spend $70,000 a year on free lunches. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have received free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university is going to try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

SACRAMENTO – Another medical school has joined what could be a growing movement to ban faculty and residents from accepting gifts from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors. “We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other schools were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. Thus, the 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article noted that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines. But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors said. They noted that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item. At the UC Davis Cancer Center alone, it is estimated that companies spend $70,000 a year on free lunches. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have received free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university is going to try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

SACRAMENTO – Another medical school has joined what could be a growing movement to ban faculty and residents from accepting gifts from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors. “We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other schools were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. Thus, the 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article noted that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines. But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors said. They noted that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item. At the UC Davis Cancer Center alone, it is estimated that companies spend $70,000 a year on free lunches. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have received free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university is going to try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

SACRAMENTO — Another medical school has joined what could be a growing movement to ban faculty and residents from accepting any gifts whatsoever from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept any gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors, he said.

“We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other academic medical centers were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. The 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article notes that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines.

But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors say. They note that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance of the policies among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item.

At the UC Davis Cancer Center alone, it is estimated that companies spend about $70,000 on free lunches a year. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have benefitted from receiving free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university will try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

SACRAMENTO — Another medical school has joined what could be a growing movement to ban faculty and residents from accepting any gifts whatsoever from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept any gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors, he said.

“We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other academic medical centers were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. The 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article notes that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines.

But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors say. They note that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance of the policies among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item.

At the UC Davis Cancer Center alone, it is estimated that companies spend about $70,000 on free lunches a year. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have benefitted from receiving free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university will try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

SACRAMENTO — Another medical school has joined what could be a growing movement to ban faculty and residents from accepting any gifts whatsoever from drug company representatives.

The University of California, Davis, Health System decided in late November to forbid its medical staff to accept any gifts from drug salesmen, including drug samples, pens, mugs, and meals, however small they might be. Earlier, the school had banned drug company representatives from walking into the clinical areas on a preceptorship.

By taking this action, the school joins a cadre of institutions that includes Yale University, which implemented its policy in 2005, the University of Pennsylvania, which did so in July 2006, and Stanford University, which implemented its policy in October 2006. At UC Davis, the policy goes into effect in July 2007.

The new prohibition “picks off the low-lying fruit” in an attempt by the institution to create a greater distance between its clinical practice and the pharmaceutical industry, said Dr. Timothy E. Albertson, the university system's executive director of clinical care.

The school has plans to look at the issue of conflict of interest in further detail, particularly in regard to relationships with and practices of other vendors, he said.

“We're certainly not trying to change capitalism, but we are trying to redefine the ethics of this type of involvement,” he said.

The efforts at UC Davis and the other academic medical centers were spurred in part by an article in the Journal of the American Medical Association (2006;295:429–33).

The article noted that many authoritative bodies, including the Pharmaceutical Research and Manufacturers of America and government agencies, have made attempts to curtail practices that constitute a conflict of interest for physicians. But the article also said those actions have largely failed to change the current climate. The 11 authors of the paper urged academic medical centers to take the lead by, among other things, banning the acceptance of gifts, samples, and payment for time spent at meetings.

Academic medical centers need to adopt such policies because the medical profession looks to them for leadership, and because academic medical centers shape the ethics of the profession, the proposal said.

The article notes that 90% of the marketing dollars spent by the pharmaceutical industry were directed at doctors, despite the increase in money spent on direct-to-consumer marketing in recent years.

According to IMS Health, a pharmaceutical information and consulting company, drug companies spent $27 billion on product promotion in 2004, of which $16 billion was for free drug samples and $7.3 billion, including gifts and meals, went to sales representative contacts.

The pharmaceutical industry, which adopted strict guidelines on gift giving in 2002, says that limiting the practices and access of their sales representatives will deprive physicians of the best expertise on their medicines.

But gifts, however insignificant, establish an unspoken quid pro quo between physicians and pharmaceutical companies. If gifts did not serve this purpose, companies would not give them, the JAMA authors say. They note that the research bears this out.

According to a 2003 survey of more than 1,000 third-year medical students, an average third-year student receives one gift or attends one company-sponsored activity a week (JAMA 2005;294:1034–42). That is precisely the point of the no-gift policies proposed by the JAMA article, said one of its authors, Dr. Jerome P. Kassirer, former editor-in-chief of the New England Journal of Medicine.

“These meals and gifts give residents and trainees the idea that pharmaceutical largesse is all right and the way things work, but it taints the profession,” Dr. Kassirer said in an interview. “They wouldn't pass out these gifts if it didn't matter.

“I think the academic medical centers needed a little nudge,” he added, noting the impact the article appears to be having. “It's a beginning.”

At the academic medical centers, free meals appear to be the biggest issue impeding acceptance of the policies among staff. The free meals allow physicians to attend midday meetings they otherwise would not have time to attend, and they are a big ticket item.

At the UC Davis Cancer Center alone, it is estimated that companies spend about $70,000 on free lunches a year. The center will now pick up those costs, and other departments may have to do the same.

At the University of Pennsylvania Health System, the adoption of its policy caused some grumbling at first, along with the loss of some legitimate educational programs that were sponsored. For the most part, however, physicians and other staff members have adjusted, said Dr. Patrick J. Brennan, the chief medical officer of the university health system.

He said there is “much less evidence” of sales representatives around the clinics and school. At one suburban clinic run by the university, sales reps turned in their identification badges in protest; but, he believes, the sales force may have adjusted. He has lately seen an increasing number of medical education programs offered to faculty and staff sponsored by a third party hired by a drug company.

At UC Davis and some of the other institutions, efforts are being made to help patients who previously might have benefitted from receiving free drug samples or devices; these items have been very helpful, especially for lower-income patients, Dr. Albertson noted. The university will try to purchase some of the equipment that has been donated in the past, such as training inhalers for asthma patients and supplies for those with diabetes. “We're going to make every effort to buy them” for use by lower-income patients, he added.

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi

PALM DESERT, CALIF. — An island pedicle flap can easily be elongated to accommodate facial anatomy and a pedicle graft for the ear's conchal bowl can come from the back of the ear, two dermatologists said in a session titled, "My Favorite Flap" at the annual meeting of the American Society for Dermatologic Surgery.

The island pedicle flap is a modest, undramatic flap that can be used to turn a round defect into a long slim defect that is easy to close, said Dr. David S. Becker, a Mohs surgeon in New York.

It does not, however, always have to be triangular in shape. In locations such as the upper lip or near the eyebrow it can be elongated to avoid creating deformity of facial features such as the vermillion, with two parallel sides before the taper.

In that case, it becomes a pentagonal pedicle, rather than a triangle, he said.

Elongating the taper also can make the defect easier to close, with less tension, he added.

In the right location, this flap rarely fails, and "if you loosen them up properly, they just float into place on a cloud of adipose tissue," Dr. Becker said.

Dr. Arash Kimyai-Asadi said that he repairs surgical defects of the front of the ear by taking a pedicle flap from the back, which he then threads through a small slit made through the cartilage.

This transcartilage, tubed, pedicle flap, as he has named it, works particularly well for defects in the conchal bowl, the triangular fossa, and the antihelix, said Dr. Kimyai-Asadi, who practices Mohs surgery in Houston.

It solves the problem of closing defects in the ear, where there is not a lot of loose skin, and he has used it to close defects 3 cm in diameter.

He said he has done 31 cases so far and has had no need for revisions, though because of swelling in the concha he has injected triamcinolone a few times.

The flap "works so well, I am using it for smaller and smaller defects now," he added. The ideal defect for the approach is one that is about 1 cm in diameter.

He makes the flap from skin on the back of the ear close to the postauricular sulcus. Then he makes what is usually a 4-mm wide incision through the cartilage, through which the pedicle flap is threaded. It is then sewn into place, and the pedicle defect is closed.

"It is a very vascular area, so you don't need a large pedicle," he said.

Because the skin matches well, "most of the time, they are very difficult to see post op," he noted.

The flap is threaded from the posterior ear through a slit in the cartilage.

The flap is shown being put into place over the defect. Photos courtesy Dr. Arash Kimyai-Asadi

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

PALM DESERT, CALIF. — The radiofrequency heating technique Thermage is probably the best studied of the technologies that tighten the skin, said Dr. Roy Geronemus at the annual meeting of the American Society for Dermatologic Surgery.

Even so, proving that the Thermage treatment works has been difficult because the effects are modest and it is hard to measure tightening objectively.

Before and after photos are simply too subjective to be of use in evaluating the effects of treatment, he said.

There have been successful attempts to be as objective as possible, mostly by demonstrating that the treatment can lift eyebrows relative to the eye pupil, said Dr. Geronemus, director of a laser practice in New York.

In a study that he conducted using Fitzpatrick wrinkle scores to make the assessment objective, he and his associates found that 57% of patients at one site and 73% of patients at another had an improvement of 25% or more in their scores at 6 months.

The investigators also used a device that attempts to measure skin tension, and found that it recorded a significant improvement in the areas of skin treated, Dr. Geronemus said.

Techniques have also evolved since Thermage was first introduced, and the better procedures have contributed to dispelling some of the skepticism, he noted. Practitioners now usually use multiple passes at a lower power level, instead of a single pass at a higher power level. The lower-power technique was used in his trial. Many physicians also recommend that a wider device tip be utilized (3 cm instead of 1.5 cm). The wider tip was not used in his trial.

Microscopic data appear to show that radiofrequency heating does result in the denaturing of collagen fibers, said Dr. Brian Zelickson, who practices in Minneapolis and is with the department of dermatology at the University of Minnesota there.

Light microscopy does not show very much effect from the Thermage technology, said Dr. Zelickson, who is a microscopy expert. An electron-microscope view of treated skin, however, shows what he called "islands" of changes in the collagen fibers.

Dr. Zelickson has also reported that one can see additive effects of each pass of the Thermage device, with up to five passes.

"In our patients, we see some modest tightening," Dr. Zelickson said. "We can certainly see some tightening of the skin when you look at the before and after pictures."

What is the most convincing evidence that Thermage works, however, is that patients have the impression that the treatment improves their looks, said Dr. Geronemus.

"Most of the patients I have seen over the last 2 months are people who are coming in for second treatments because of the success they have achieved with their first treatment with Thermage," he said.

Still, even these two experts expressed some reservations about what can actually be accomplished with Thermage's ThermaCool system.

The procedure does not appear to be appropriate for all of his patients, said Dr. Zelickson.

In his experience, selecting the proper patient is crucial to obtaining a good result, but he did not elaborate on his criteria any further except to say that the right patient is one with obvious skin "laxity."

Dr. Geronemus noted that in his research there was some evidence that the benefits of Thermage treatment appeared to be wearing off after a period of about 6 months.

Dr. Zelickson has received research grants from Thermage Inc., and Dr. Geronemus is a company shareholder.

Proving that Thermage works is difficult because the effects are modest and it is hard to measure tightening. DR. GERONEMUS

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

PALM DESERT, CALIF. — A better method for skin grafting surgical defects of the nasal alar region may be what Dr. Bradley K. Draper calls a "drumhead" graft.

Deep alar defects can be difficult to graft without leaving a sunken depression, and a graft that fails can compromise nasal support and compromise breathing through that nasal passage, Dr. Draper said at the annual meeting of the American Society for Dermatologic Surgery.

So, he devised a technique in which gauze supports are attached to both sides of the graft and defect to pull the wound bed up to a tight graft, resulting in a better cosmetic and functional result.

Dr. Draper, a Mohs surgeon in Billings, Mont., described performing the graft on patients with Mohs defects that were up to 1 cm in depth, on the lower third of the nose.

To perform his drumhead technique, Dr. Draper explained he harvests the graft tissue from either the postauricular region or below the earlobe for the best tissue match.

He fashions the graft so that it is slightly smaller than the defect, so that when it is sutured into place it is tight over the defect like a drumhead.

Once the graft is sutured into place, Dr. Draper drives a 4.0 Prolene suture through the graft and the nasal mucosa into the nasal vestibule. He then returns the suture through the mucosa and the graft, leaving a loop. Into the loop, he puts a gauze bolster impregnated with antibiotic ointment, which is pulled up into the vestibule against the mucosa.

Dr. Draper explained that he next creates a strut out of the inner packing material of the suture package, and then ties that to the top of the graft.

The assembly of bolster and strut "accomplishes two things," Dr. Draper said at the meeting. "It provides a suspensory effect over the surface of the graft, as well as pulls the intranasal bolster taut up against the graft bed so the bed comes into contact with the overlying skin graft."

The assembly remains in place for 10 days, which is the only real drawback of the technique.

"If you do this, tell your patients that you understand that they are not going to like having that intranasal bolster but that it is necessary," Dr. Draper said.

Attaching a strut produces pressure on the back of the graft for 10 days. Courtesy Dr. Bradley K. Draper

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2.3 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 a year subsidy for prescription drugs under the previous Medicare program will no longer qualify for such a subsidy.

Also, the analysis showed that 16%–23% will probably end up in what is called the “doughnut hole” of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a leading pharmacy-benefits management company.

To conduct the presented analysis, Mr. Roebuck and his fellow colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at 6 months or longer, and who had filled at least one prescription.

The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

“We think one of the strong points of our research is that it is based on actual claims data,” he said.

The enrollees filled a mean of 19 prescriptions per year, 10 of which were for generic medications and 9 for brand name. The mean total cost for their prescriptions was $849, of which they paid a mean $538 out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually.

Those who are in the low income category and who currently qualify for the $600 subsidy could face an increase in out-of-pocket costs in the range of $58 to $86 annually, provided they still qualified for the subsidy.

Those increased costs could mean that some would choose to forgo some prescriptions, decisions that could have health consequences.

On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41–$55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62–$71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by $2 billion to $2.3 billion annually, Mr. Roebuck said.

The 10% increase in the use of generics would also reduce the number of these beneficiaries who would get into the doughnut hole by 1%–2%.

The so-called Medicare Part D doughnut hole—where Medicare Part D stops coverage—kicks in when a patient has spent $2,250 on drugs and lasts until they have spent $5,100, at which point coverage begins again.

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2.3 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 a year subsidy for prescription drugs under the previous Medicare program will no longer qualify for such a subsidy.

Also, the analysis showed that 16%–23% will probably end up in what is called the “doughnut hole” of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a leading pharmacy-benefits management company.

To conduct the presented analysis, Mr. Roebuck and his fellow colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at 6 months or longer, and who had filled at least one prescription.

The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

“We think one of the strong points of our research is that it is based on actual claims data,” he said.

The enrollees filled a mean of 19 prescriptions per year, 10 of which were for generic medications and 9 for brand name. The mean total cost for their prescriptions was $849, of which they paid a mean $538 out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually.

Those who are in the low income category and who currently qualify for the $600 subsidy could face an increase in out-of-pocket costs in the range of $58 to $86 annually, provided they still qualified for the subsidy.

Those increased costs could mean that some would choose to forgo some prescriptions, decisions that could have health consequences.

On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41–$55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62–$71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by $2 billion to $2.3 billion annually, Mr. Roebuck said.

The 10% increase in the use of generics would also reduce the number of these beneficiaries who would get into the doughnut hole by 1%–2%.

The so-called Medicare Part D doughnut hole—where Medicare Part D stops coverage—kicks in when a patient has spent $2,250 on drugs and lasts until they have spent $5,100, at which point coverage begins again.

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2.3 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 a year subsidy for prescription drugs under the previous Medicare program will no longer qualify for such a subsidy.

Also, the analysis showed that 16%–23% will probably end up in what is called the “doughnut hole” of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a leading pharmacy-benefits management company.

To conduct the presented analysis, Mr. Roebuck and his fellow colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at 6 months or longer, and who had filled at least one prescription.

The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

“We think one of the strong points of our research is that it is based on actual claims data,” he said.

The enrollees filled a mean of 19 prescriptions per year, 10 of which were for generic medications and 9 for brand name. The mean total cost for their prescriptions was $849, of which they paid a mean $538 out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually.

Those who are in the low income category and who currently qualify for the $600 subsidy could face an increase in out-of-pocket costs in the range of $58 to $86 annually, provided they still qualified for the subsidy.

Those increased costs could mean that some would choose to forgo some prescriptions, decisions that could have health consequences.

On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41–$55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62–$71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by $2 billion to $2.3 billion annually, Mr. Roebuck said.

The 10% increase in the use of generics would also reduce the number of these beneficiaries who would get into the doughnut hole by 1%–2%.

The so-called Medicare Part D doughnut hole—where Medicare Part D stops coverage—kicks in when a patient has spent $2,250 on drugs and lasts until they have spent $5,100, at which point coverage begins again.

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 subsidy for prescription drugs under the previous Medicare program will no longer qualify for a subsidy, and 16%–23% will probably end up in what is called the doughnut hole of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a pharmacy-benefits management company.

To conduct the analysis, Mr. Roebuck and colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at least 6 months, and who had filled at least one prescription. The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

The enrollees filled a mean of 19 prescriptions per year, 10 for generic drugs and 9 for brand name, for a mean total cost of $849, of which $538 was paid out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually. On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41 to $55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62 to $71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by about $2 billion annually, Mr. Roebuck said.

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 subsidy for prescription drugs under the previous Medicare program will no longer qualify for a subsidy, and 16%–23% will probably end up in what is called the doughnut hole of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a pharmacy-benefits management company.

To conduct the analysis, Mr. Roebuck and colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at least 6 months, and who had filled at least one prescription. The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

The enrollees filled a mean of 19 prescriptions per year, 10 for generic drugs and 9 for brand name, for a mean total cost of $849, of which $538 was paid out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually. On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41 to $55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62 to $71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by about $2 billion annually, Mr. Roebuck said.

SEATTLE — With generic prescribing, a little can go a long way. In fact, by using generics 10% of the time, the Medicare Part D program could reduce drug spending by as much as $2 billion, according to an analysis presented at the annual research meeting of Academy Health.

That could be important because the analysis also showed that about 22% of Medicare beneficiaries who used to receive a $600 subsidy for prescription drugs under the previous Medicare program will no longer qualify for a subsidy, and 16%–23% will probably end up in what is called the doughnut hole of Medicare Part D, where they will have no drug coverage, said M. Christopher Roebuck, an economist with CareMark, Hunt Valley, Md., a pharmacy-benefits management company.

To conduct the analysis, Mr. Roebuck and colleagues used data from 37,425 individuals enrolled in Medicare drug discount card programs for at least 6 months, and who had filled at least one prescription. The researchers then assumed those same usage patterns, with some increase in usage when out-of-pocket costs go down, and applied a 3.5% annual rate for inflation.

The enrollees filled a mean of 19 prescriptions per year, 10 for generic drugs and 9 for brand name, for a mean total cost of $849, of which $538 was paid out of pocket.

Depending on the assumption used to estimate how the new coverage might increase use, the analysis suggests that out-of-pocket costs could increase for these beneficiaries by $38 to $187 annually. On the other hand, if the generic prescription rate were increased by 10%, it would save the beneficiaries a mean amount in the range of $41 to $55 in out-of-pocket costs and would decrease the amount spent by Medicare on each beneficiary by $62 to $71.

Extrapolating that to 33 million beneficiaries, Medicare could reduce its spending by about $2 billion annually, Mr. Roebuck said.

SEATTLE — Obesity costs the United States $49 billion for each group of 4 million children born, according to findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese—from ages 3 to 65—for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is composed of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide. However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

SEATTLE — Obesity costs the United States $49 billion for each group of 4 million children born, according to findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese—from ages 3 to 65—for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is composed of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide. However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

SEATTLE — Obesity costs the United States $49 billion for each group of 4 million children born, according to findings presented by Dr. Matthew M. Davis at the annual research meeting of AcademyHealth.

That $49 billion figure reflects the present rate of obesity, not the expanding rate actually occurring, said Dr. Davis of the department of pediatrics and internal medicine at the University of Michigan, Ann Arbor.

Dr. Davis' research involved constructing a model that calculated the longitudinal costs of being obese—from ages 3 to 65—for the percentage of individuals who are obese at every age. Currently, the average number of children born annually is 4 million.

The model suggests that the percentage of individuals who are overweight or obese does not really change much before age 16, because some individuals gain and lose weight as they grow and cycle from being overweight to normal weight. But that percentage begins to climb at age 16 years, as the likelihood of being overweight or becoming overweight at that age and then returning to a normal weight declines. The rate begins its steepest climb when individuals are about 25–35 years of age.

Significant differences in health care costs for persons who are obese do not begin to occur before age 40 years, Dr. Davis said. But then they continue to increase so that by age 50 each individual incurs excess costs averaging $2,000 a year.

The $49 billion extra spent for obese individuals between the ages of 3 and 65 is composed of $44 billion in direct health care costs and $5 billion in days of lost work.

Dr. Davis also attempted to predict what impact various proven obesity interventions would have if they were implemented nationwide. However, he found he could not, because none of the studies about those interventions had any longitudinal information on the individuals once the intervention was stopped.

He said there are five public health interventions that most experts agree have been shown to work to reduce obesity rates. All of those interventions involve targeting children, most between 9 and 12 years of age. The intervention shown to have the biggest impact is eliminating the sale of soda in schools, Dr. Davis said.

In his study, Dr. Davis had to assume the effect of the interventions stopped when the intervention ceased; in such a scenario, the interventions had minimal impact. Getting soft drinks out of schools would save only about $650 million. All of the other four interventions combined would save another $300 million.

Dr. Davis' data were culled from a variety of sources, including the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey.

ASPEN, COLO. — The risk that a sore throat will lead to rheumatic fever has always been vastly exaggerated, and it may be lower now than it once was. In fact, the risk is one of the major myths of medicine, Dr. Michael Radetsky said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

That means any approach—rapid antigen test or culture, or empiric treatment or not—can be justified, said Dr. Radetsky, a pediatric infectious diseases consultant from Albuquerque, N.M.

“The whole issue of strep disease is now shifting from an issue of real medicine—meaning treating real disease—to an issue of relationship with the family,” he said.

Last year, a group at Michigan State University, East Lansing, attempted to develop a rule for when to use a rapid antigen test versus when to culture a patient with pharyngitis for group A hemolytic streptococcus (GAS) infection, based on a cost analysis. Their investigation is very enlightening, Dr. Radetsky said.

The article raises “every serious issue that if we had time we would be thinking about, regarding what we should do about the entire issue of looking for strep throat,” he said. The first interesting facet of this study is that in their analysis the researchers found that there are no current, accurate estimates for calculating the risk and incidence of peritonsillar abscess or acute rheumatic fever.

To develop their risk estimate of acute rheumatic fever, they had to go back to 1961, to the outbreak in New York City in which there were 2 cases among 608 cases of untreated GAS—for an incidence of 0.328% (Pediatrics 2006;117:609–19).

Since then—according to the available, albeit scanty, evidence—the incidence of GAS has been reduced by 98%. So the investigators multiplied 0.328 by 2%, which gave them a current estimate of a risk of acute rheumatic fever of 1 in 15,000 cases of untreated disease. Of those, only 10% will have complications and 1% will die, while treatment appears to reduce the risk of acute rheumatic fever by 88%, the study concluded.

“That was their estimate; I don't think anyone has done it better,” Dr. Radetsky said.

The incidence of peritonsillar abscess, also never well studied, has been estimated at 0.5%–3%, and treatment of pharyngitis appears to reduce the incidence by only one-sixth or one-ninth, the investigators said.

They concluded in their analysis that treatment needed to be based on some kind of testing, because treating everyone and treating no one were not cost-effective. But, whether a rapid test or a culture is used depends on the costs, which vary in different areas.

But Dr. Radetsky said the study needs to be given deeper consideration.

The study shows that the risk of any kind of complication in a patient is extremely low.

The rationale for treating streptococcal pharyngitis has evolved over the years, he noted. Initially, it was to prevent rheumatic fever. Then it was to prevent peritonsillar abscess. Now it is also justified to enhance recovery and prevent contagion.

But, treatment has been shown not to speed recovery much, and treating to prevent contagion also is not likely to make much difference, because it is estimated that for every patient with a sore throat who sees a doctor, four to six people do not. Moreover, 15% of schoolchildren at any one time are carriers of GAS, so it is more likely that any one patient with GAS will acquire it at school than that they will be the source of an outbreak.

Given those facts, the physician has two obligations regarding GAS, Dr. Radetsky said.

One is to practice in whatever way fosters the therapeutic relationship with a patient and his or her family.

The second is to confine antibiotic use.

He recommended using a culture rather than a rapid antigen test or not testing at all to confine antibiotic use. That way, you give the patient a few days to get better before prescribing. To the family, the physician can explain that, even if the child does have GAS, waiting a few days will give the child a better opportunity to develop immunity to that particular serotype.

Moreover, treating with a second- or third-generation cephalosporin for 5 days, instead of using penicillin for 10 days, reduces the use of antibiotics and probably has superior efficacy, at least according to one recent metaanalysis (Pediatr. Infect. Dis. J. 2005;24:909–17).

“You have just cut the number of days on antibiotics in half,” he said.

Dr. Radetsky also advocated using the technique of the deferred prescription, to be used only if the culture comes back positive or if the patient gets worse.

“The justification for doing what we do is becoming slimmer and slimmer, so that the continued pursuit of group A streptococcal pharyngitis is really driven by an outdated notion of risk, and a self-perpetuated habit,” he added.

ASPEN, COLO. — The risk that a sore throat will lead to rheumatic fever has always been vastly exaggerated, and it may be lower now than it once was. In fact, the risk is one of the major myths of medicine, Dr. Michael Radetsky said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

That means any approach—rapid antigen test or culture, or empiric treatment or not—can be justified, said Dr. Radetsky, a pediatric infectious diseases consultant from Albuquerque, N.M.

“The whole issue of strep disease is now shifting from an issue of real medicine—meaning treating real disease—to an issue of relationship with the family,” he said.

Last year, a group at Michigan State University, East Lansing, attempted to develop a rule for when to use a rapid antigen test versus when to culture a patient with pharyngitis for group A hemolytic streptococcus (GAS) infection, based on a cost analysis. Their investigation is very enlightening, Dr. Radetsky said.

The article raises “every serious issue that if we had time we would be thinking about, regarding what we should do about the entire issue of looking for strep throat,” he said. The first interesting facet of this study is that in their analysis the researchers found that there are no current, accurate estimates for calculating the risk and incidence of peritonsillar abscess or acute rheumatic fever.

To develop their risk estimate of acute rheumatic fever, they had to go back to 1961, to the outbreak in New York City in which there were 2 cases among 608 cases of untreated GAS—for an incidence of 0.328% (Pediatrics 2006;117:609–19).

Since then—according to the available, albeit scanty, evidence—the incidence of GAS has been reduced by 98%. So the investigators multiplied 0.328 by 2%, which gave them a current estimate of a risk of acute rheumatic fever of 1 in 15,000 cases of untreated disease. Of those, only 10% will have complications and 1% will die, while treatment appears to reduce the risk of acute rheumatic fever by 88%, the study concluded.

“That was their estimate; I don't think anyone has done it better,” Dr. Radetsky said.

The incidence of peritonsillar abscess, also never well studied, has been estimated at 0.5%–3%, and treatment of pharyngitis appears to reduce the incidence by only one-sixth or one-ninth, the investigators said.

They concluded in their analysis that treatment needed to be based on some kind of testing, because treating everyone and treating no one were not cost-effective. But, whether a rapid test or a culture is used depends on the costs, which vary in different areas.

But Dr. Radetsky said the study needs to be given deeper consideration.

The study shows that the risk of any kind of complication in a patient is extremely low.

The rationale for treating streptococcal pharyngitis has evolved over the years, he noted. Initially, it was to prevent rheumatic fever. Then it was to prevent peritonsillar abscess. Now it is also justified to enhance recovery and prevent contagion.

But, treatment has been shown not to speed recovery much, and treating to prevent contagion also is not likely to make much difference, because it is estimated that for every patient with a sore throat who sees a doctor, four to six people do not. Moreover, 15% of schoolchildren at any one time are carriers of GAS, so it is more likely that any one patient with GAS will acquire it at school than that they will be the source of an outbreak.

Given those facts, the physician has two obligations regarding GAS, Dr. Radetsky said.

One is to practice in whatever way fosters the therapeutic relationship with a patient and his or her family.

The second is to confine antibiotic use.

He recommended using a culture rather than a rapid antigen test or not testing at all to confine antibiotic use. That way, you give the patient a few days to get better before prescribing. To the family, the physician can explain that, even if the child does have GAS, waiting a few days will give the child a better opportunity to develop immunity to that particular serotype.

Moreover, treating with a second- or third-generation cephalosporin for 5 days, instead of using penicillin for 10 days, reduces the use of antibiotics and probably has superior efficacy, at least according to one recent metaanalysis (Pediatr. Infect. Dis. J. 2005;24:909–17).

“You have just cut the number of days on antibiotics in half,” he said.

Dr. Radetsky also advocated using the technique of the deferred prescription, to be used only if the culture comes back positive or if the patient gets worse.

“The justification for doing what we do is becoming slimmer and slimmer, so that the continued pursuit of group A streptococcal pharyngitis is really driven by an outdated notion of risk, and a self-perpetuated habit,” he added.

ASPEN, COLO. — The risk that a sore throat will lead to rheumatic fever has always been vastly exaggerated, and it may be lower now than it once was. In fact, the risk is one of the major myths of medicine, Dr. Michael Radetsky said at a conference on pediatric infectious diseases sponsored by Children's Hospital, Denver.

That means any approach—rapid antigen test or culture, or empiric treatment or not—can be justified, said Dr. Radetsky, a pediatric infectious diseases consultant from Albuquerque, N.M.

“The whole issue of strep disease is now shifting from an issue of real medicine—meaning treating real disease—to an issue of relationship with the family,” he said.

Last year, a group at Michigan State University, East Lansing, attempted to develop a rule for when to use a rapid antigen test versus when to culture a patient with pharyngitis for group A hemolytic streptococcus (GAS) infection, based on a cost analysis. Their investigation is very enlightening, Dr. Radetsky said.

The article raises “every serious issue that if we had time we would be thinking about, regarding what we should do about the entire issue of looking for strep throat,” he said. The first interesting facet of this study is that in their analysis the researchers found that there are no current, accurate estimates for calculating the risk and incidence of peritonsillar abscess or acute rheumatic fever.

To develop their risk estimate of acute rheumatic fever, they had to go back to 1961, to the outbreak in New York City in which there were 2 cases among 608 cases of untreated GAS—for an incidence of 0.328% (Pediatrics 2006;117:609–19).

Since then—according to the available, albeit scanty, evidence—the incidence of GAS has been reduced by 98%. So the investigators multiplied 0.328 by 2%, which gave them a current estimate of a risk of acute rheumatic fever of 1 in 15,000 cases of untreated disease. Of those, only 10% will have complications and 1% will die, while treatment appears to reduce the risk of acute rheumatic fever by 88%, the study concluded.

“That was their estimate; I don't think anyone has done it better,” Dr. Radetsky said.

The incidence of peritonsillar abscess, also never well studied, has been estimated at 0.5%–3%, and treatment of pharyngitis appears to reduce the incidence by only one-sixth or one-ninth, the investigators said.

They concluded in their analysis that treatment needed to be based on some kind of testing, because treating everyone and treating no one were not cost-effective. But, whether a rapid test or a culture is used depends on the costs, which vary in different areas.

But Dr. Radetsky said the study needs to be given deeper consideration.

The study shows that the risk of any kind of complication in a patient is extremely low.

The rationale for treating streptococcal pharyngitis has evolved over the years, he noted. Initially, it was to prevent rheumatic fever. Then it was to prevent peritonsillar abscess. Now it is also justified to enhance recovery and prevent contagion.

But, treatment has been shown not to speed recovery much, and treating to prevent contagion also is not likely to make much difference, because it is estimated that for every patient with a sore throat who sees a doctor, four to six people do not. Moreover, 15% of schoolchildren at any one time are carriers of GAS, so it is more likely that any one patient with GAS will acquire it at school than that they will be the source of an outbreak.

Given those facts, the physician has two obligations regarding GAS, Dr. Radetsky said.

One is to practice in whatever way fosters the therapeutic relationship with a patient and his or her family.

The second is to confine antibiotic use.

He recommended using a culture rather than a rapid antigen test or not testing at all to confine antibiotic use. That way, you give the patient a few days to get better before prescribing. To the family, the physician can explain that, even if the child does have GAS, waiting a few days will give the child a better opportunity to develop immunity to that particular serotype.

Moreover, treating with a second- or third-generation cephalosporin for 5 days, instead of using penicillin for 10 days, reduces the use of antibiotics and probably has superior efficacy, at least according to one recent metaanalysis (Pediatr. Infect. Dis. J. 2005;24:909–17).

“You have just cut the number of days on antibiotics in half,” he said.

Dr. Radetsky also advocated using the technique of the deferred prescription, to be used only if the culture comes back positive or if the patient gets worse.

“The justification for doing what we do is becoming slimmer and slimmer, so that the continued pursuit of group A streptococcal pharyngitis is really driven by an outdated notion of risk, and a self-perpetuated habit,” he added.

ASPEN, COLO. — The molecular DNA techniques of the past few years have shed much new light on rhinovirus infection, including the fact that rhinovirus causes more lower respiratory tract infections than previously thought and that there may be a possible connection between early infection and asthma.

The new techniques, most of which utilize polymerase chain reaction technology, allow the virus to be detected and identified much more precisely than before. Some serotypes of rhinovirus cannot be cultured, said Dr. Adriana Weinberg, the medical director of the clinical virology laboratory at the University of Colorado Hospital, Denver.

Studies using these techniques now have shown that rhinovirus is associated with both bronchiolitis and pneumonia, Dr. Weinberg said.

In one study of 239 hospitalized Finnish children with bronchiolitis, rhinovirus was the second most common virus recovered from children who were less than 1 year of age (42%), just behind respiratory syncytial virus (54%). In the children who were older than 1 year, rhinovirus was more common than respiratory syncytial virus (Emerg. Infect. Dis. 2004;10:1095–101).

A few studies have looked at rhinovirus infection in children with community-acquired pneumonia (CAP). Those studies have shown that 24% of children less than 5 years of age with CAP tested positive for a rhinovirus infection. Among school-age children, 45% of pneumonia cases had a rhinovirus infection, Dr. Weinberg said.

None of the studies had control subjects, Dr. Weinberg said. There are few studies of lower respiratory tract infection and rhinovirus that do. Moreover, in many cases, the study children did have mixed infections, either another virus or a bacterial infection.

Therefore, while this information about rhinovirus and lower respiratory tract infection is obviously important, it is not necessarily in context yet, Dr. Weinberg said.

In general, mixed infections are thought to have the most severe morbidity and symptoms. And in one study that did look at whether infections were mixed or only rhinovirus and whether the “mixed” was another virus or bacteria, there was not much difference in the rates of the recovery from other viruses or bacteria—for the lower age groups at least (less than 14 months)—in the subjects who were symptomatic with a lower respiratory tract infection, compared with those who were asymptomatic, she said.

That argues that the rhinovirus is playing some role, because the rates of rhinoviral infection were different in the symptomatic and asymptomatic patients, Dr. Weinberg said.

Regarding the asthma association, Dr. Weinberg again said that there are a collection of studies that have made this observation; that is, that early infection with rhinovirus appears to increase the likelihood a child will later develop asthma.

Some of the studies have tracked the cohorts since birth, and some have been case-control studies. They have ranged in size from 100 patients to 1,314 patients and have tended to have fairly rigorous criteria for diagnosing asthma.

One theory about why rhinovirus infection would predispose toward asthma is that the infection causes some kind of physical remodeling in a developing and evolving respiratory tract. Another is that early infections prime the dendritic cells of the immune system to be hyperreactive.

Taken together and individually, the studies have suggested that severe and/or repeated lower respiratory tract infections before age 2–3 years increases the prevalence of asthma 10 times. That compares with a five-fold increase the studies have found for respiratory syncytial virus.

Of course, none of these studies provides any explanation about how this association would fit with the other, contradictory epidemiologic studies suggesting that children have increased risk of asthma when they are protected from certain infections and exposures.

“A lot of work remains to be done to fully understand the mechanism and to fully determine whether early rhinoviral infections are a cause of asthma,” Dr. Weinberg commented.

Recent work also showed that infections with rhinovirus can be severe, she noted. In a big study of the antiviral oseltamivir for influenza treatment, it was found that 19% of the patients enrolled, based on their symptoms, actually had rhinovirus infection. In those patients, the drug was not effective, but the clinical presentation was extremely similar, the investigators noted.

“Rhinovirus is much more serious than we used to think—at least in terms of morbidity,” Dr. Weinberg said.

A number of facts that were known previously about rhinovirus have been confirmed by modern study, according to Dr. Weinberg.

Those facts include the following:

▸ Rhinovirus accounts for about 30%–50% of all “common colds.”

▸ Rhinovirus is highly contagious. About two-thirds of individuals exposed to the virus will acquire an infection and develop symptoms.

▸ The incubation period is about 12 hours.

▸ The duration of symptoms of an infection usually last 2–3 days, but in 25% of cases can last up to 2 weeks.

▸ By age 4, most individuals have had about five infections with rhinovirus.

Dr. Weinberg also noted that human rhinoviruses, of which there are about 100 different serotypes, do not have a lipid coat, which means they are not affected by sterilization using organic solvents like soap or alcohol. Instead, if one wants to clean surfaces that have been around someone with rhinovirus, one has to use something acidic. “You may want to decontaminate objects with lemon juice or vinegar,” she said.

ASPEN, COLO. — The molecular DNA techniques of the past few years have shed much new light on rhinovirus infection, including the fact that rhinovirus causes more lower respiratory tract infections than previously thought and that there may be a possible connection between early infection and asthma.

The new techniques, most of which utilize polymerase chain reaction technology, allow the virus to be detected and identified much more precisely than before. Some serotypes of rhinovirus cannot be cultured, said Dr. Adriana Weinberg, the medical director of the clinical virology laboratory at the University of Colorado Hospital, Denver.

Studies using these techniques now have shown that rhinovirus is associated with both bronchiolitis and pneumonia, Dr. Weinberg said.

In one study of 239 hospitalized Finnish children with bronchiolitis, rhinovirus was the second most common virus recovered from children who were less than 1 year of age (42%), just behind respiratory syncytial virus (54%). In the children who were older than 1 year, rhinovirus was more common than respiratory syncytial virus (Emerg. Infect. Dis. 2004;10:1095–101).

A few studies have looked at rhinovirus infection in children with community-acquired pneumonia (CAP). Those studies have shown that 24% of children less than 5 years of age with CAP tested positive for a rhinovirus infection. Among school-age children, 45% of pneumonia cases had a rhinovirus infection, Dr. Weinberg said.

None of the studies had control subjects, Dr. Weinberg said. There are few studies of lower respiratory tract infection and rhinovirus that do. Moreover, in many cases, the study children did have mixed infections, either another virus or a bacterial infection.

Therefore, while this information about rhinovirus and lower respiratory tract infection is obviously important, it is not necessarily in context yet, Dr. Weinberg said.

In general, mixed infections are thought to have the most severe morbidity and symptoms. And in one study that did look at whether infections were mixed or only rhinovirus and whether the “mixed” was another virus or bacteria, there was not much difference in the rates of the recovery from other viruses or bacteria—for the lower age groups at least (less than 14 months)—in the subjects who were symptomatic with a lower respiratory tract infection, compared with those who were asymptomatic, she said.

That argues that the rhinovirus is playing some role, because the rates of rhinoviral infection were different in the symptomatic and asymptomatic patients, Dr. Weinberg said.

Regarding the asthma association, Dr. Weinberg again said that there are a collection of studies that have made this observation; that is, that early infection with rhinovirus appears to increase the likelihood a child will later develop asthma.

Some of the studies have tracked the cohorts since birth, and some have been case-control studies. They have ranged in size from 100 patients to 1,314 patients and have tended to have fairly rigorous criteria for diagnosing asthma.

One theory about why rhinovirus infection would predispose toward asthma is that the infection causes some kind of physical remodeling in a developing and evolving respiratory tract. Another is that early infections prime the dendritic cells of the immune system to be hyperreactive.

Taken together and individually, the studies have suggested that severe and/or repeated lower respiratory tract infections before age 2–3 years increases the prevalence of asthma 10 times. That compares with a five-fold increase the studies have found for respiratory syncytial virus.

Of course, none of these studies provides any explanation about how this association would fit with the other, contradictory epidemiologic studies suggesting that children have increased risk of asthma when they are protected from certain infections and exposures.

“A lot of work remains to be done to fully understand the mechanism and to fully determine whether early rhinoviral infections are a cause of asthma,” Dr. Weinberg commented.

Recent work also showed that infections with rhinovirus can be severe, she noted. In a big study of the antiviral oseltamivir for influenza treatment, it was found that 19% of the patients enrolled, based on their symptoms, actually had rhinovirus infection. In those patients, the drug was not effective, but the clinical presentation was extremely similar, the investigators noted.

“Rhinovirus is much more serious than we used to think—at least in terms of morbidity,” Dr. Weinberg said.

A number of facts that were known previously about rhinovirus have been confirmed by modern study, according to Dr. Weinberg.

Those facts include the following:

▸ Rhinovirus accounts for about 30%–50% of all “common colds.”

▸ Rhinovirus is highly contagious. About two-thirds of individuals exposed to the virus will acquire an infection and develop symptoms.

▸ The incubation period is about 12 hours.

▸ The duration of symptoms of an infection usually last 2–3 days, but in 25% of cases can last up to 2 weeks.

▸ By age 4, most individuals have had about five infections with rhinovirus.

Dr. Weinberg also noted that human rhinoviruses, of which there are about 100 different serotypes, do not have a lipid coat, which means they are not affected by sterilization using organic solvents like soap or alcohol. Instead, if one wants to clean surfaces that have been around someone with rhinovirus, one has to use something acidic. “You may want to decontaminate objects with lemon juice or vinegar,” she said.

ASPEN, COLO. — The molecular DNA techniques of the past few years have shed much new light on rhinovirus infection, including the fact that rhinovirus causes more lower respiratory tract infections than previously thought and that there may be a possible connection between early infection and asthma.

The new techniques, most of which utilize polymerase chain reaction technology, allow the virus to be detected and identified much more precisely than before. Some serotypes of rhinovirus cannot be cultured, said Dr. Adriana Weinberg, the medical director of the clinical virology laboratory at the University of Colorado Hospital, Denver.

Studies using these techniques now have shown that rhinovirus is associated with both bronchiolitis and pneumonia, Dr. Weinberg said.

In one study of 239 hospitalized Finnish children with bronchiolitis, rhinovirus was the second most common virus recovered from children who were less than 1 year of age (42%), just behind respiratory syncytial virus (54%). In the children who were older than 1 year, rhinovirus was more common than respiratory syncytial virus (Emerg. Infect. Dis. 2004;10:1095–101).

A few studies have looked at rhinovirus infection in children with community-acquired pneumonia (CAP). Those studies have shown that 24% of children less than 5 years of age with CAP tested positive for a rhinovirus infection. Among school-age children, 45% of pneumonia cases had a rhinovirus infection, Dr. Weinberg said.

None of the studies had control subjects, Dr. Weinberg said. There are few studies of lower respiratory tract infection and rhinovirus that do. Moreover, in many cases, the study children did have mixed infections, either another virus or a bacterial infection.

Therefore, while this information about rhinovirus and lower respiratory tract infection is obviously important, it is not necessarily in context yet, Dr. Weinberg said.

In general, mixed infections are thought to have the most severe morbidity and symptoms. And in one study that did look at whether infections were mixed or only rhinovirus and whether the “mixed” was another virus or bacteria, there was not much difference in the rates of the recovery from other viruses or bacteria—for the lower age groups at least (less than 14 months)—in the subjects who were symptomatic with a lower respiratory tract infection, compared with those who were asymptomatic, she said.

That argues that the rhinovirus is playing some role, because the rates of rhinoviral infection were different in the symptomatic and asymptomatic patients, Dr. Weinberg said.

Regarding the asthma association, Dr. Weinberg again said that there are a collection of studies that have made this observation; that is, that early infection with rhinovirus appears to increase the likelihood a child will later develop asthma.

Some of the studies have tracked the cohorts since birth, and some have been case-control studies. They have ranged in size from 100 patients to 1,314 patients and have tended to have fairly rigorous criteria for diagnosing asthma.

One theory about why rhinovirus infection would predispose toward asthma is that the infection causes some kind of physical remodeling in a developing and evolving respiratory tract. Another is that early infections prime the dendritic cells of the immune system to be hyperreactive.

Taken together and individually, the studies have suggested that severe and/or repeated lower respiratory tract infections before age 2–3 years increases the prevalence of asthma 10 times. That compares with a five-fold increase the studies have found for respiratory syncytial virus.

Of course, none of these studies provides any explanation about how this association would fit with the other, contradictory epidemiologic studies suggesting that children have increased risk of asthma when they are protected from certain infections and exposures.

“A lot of work remains to be done to fully understand the mechanism and to fully determine whether early rhinoviral infections are a cause of asthma,” Dr. Weinberg commented.

Recent work also showed that infections with rhinovirus can be severe, she noted. In a big study of the antiviral oseltamivir for influenza treatment, it was found that 19% of the patients enrolled, based on their symptoms, actually had rhinovirus infection. In those patients, the drug was not effective, but the clinical presentation was extremely similar, the investigators noted.

“Rhinovirus is much more serious than we used to think—at least in terms of morbidity,” Dr. Weinberg said.

A number of facts that were known previously about rhinovirus have been confirmed by modern study, according to Dr. Weinberg.

Those facts include the following:

▸ Rhinovirus accounts for about 30%–50% of all “common colds.”

▸ Rhinovirus is highly contagious. About two-thirds of individuals exposed to the virus will acquire an infection and develop symptoms.

▸ The incubation period is about 12 hours.

▸ The duration of symptoms of an infection usually last 2–3 days, but in 25% of cases can last up to 2 weeks.

▸ By age 4, most individuals have had about five infections with rhinovirus.

Dr. Weinberg also noted that human rhinoviruses, of which there are about 100 different serotypes, do not have a lipid coat, which means they are not affected by sterilization using organic solvents like soap or alcohol. Instead, if one wants to clean surfaces that have been around someone with rhinovirus, one has to use something acidic. “You may want to decontaminate objects with lemon juice or vinegar,” she said.