Tuesday, April 24, 2012

Watch an Insurance Company Try to Drive Me Insane..Yet Again

Well, I guess I'm sort of creating a series about insurance company insanity.  I didn't start out meaning to do it, but so many opportunities keep presenting themselves!  Here's a new one.  One of my patients needed to get a specific type of stress test.  Of course, I can't just order it.  No.  It has to be approved by her insurance company, via a middleman company that runs their approval process.  So, first we call them for approval.  Then we send a copy of my office notes.  Then, without fail, this happens.

This message  says that my office notes that I sent them don't meet their clinical guidelines for approval.  I need to call them and talk to the physician reviewer to plead my case.  Note that the message was received at 4:45 PM.  Convenient.  I was not able to return the call that business day.  A good thing, too, since the next morning first thing off the fax, is this:

A notice saying they've approved the stress test, even though about 12 hours before they had denied it.  I never called them.  So, what happened between 4:45 PM on April 23 and 8 AM on April 24?   I have no idea.  Nor do I wish to look a gift horse in the mouth.  However, the best part of that approval fax is that right after we got it, we got this:

Yup.  You read it right.  Another request for additional clinical information, for the test they had already approved.

Just another day at the office.  Just another gray hair.

Tuesday, April 17, 2012

Marni's Army is Hitting the Road

It's hard for me to believe, but it's been 8 years since I started the Beacon Runners (AKA Marni's Army).  Back then, I was young and idealistic.  More importantly, I didn't have kids yet and had loads of free time.  At the time, I had been running for about 4 years- I started running during my residency so I could get some exercise and stress relief.  During my first year in practice here in NH, I got tired of just lecturing all my patients on the importance of exercise.  I decided to put my money where my mouth was and actually get out there and exercise with my them.  Every year the group has gotten bigger, and it's wonderful to see familiar faces returning year after year.  It's great that eight years later we are still going strong, meeting every Tuesday and Saturday in April and May.

There was a great turnout tonight- how can you beat 80 degree weather and a great evening run at the beach?

Monday, April 16, 2012

Watch an Insurance company try to drive me insane...again

More formulary exemption/prior authorization fun!  This one says that the patient's blood pressure pill, Cardizem CD, is not covered and it is non-formulary.  They helpfully tell me what the formulary alternative is: diltiazem CD, which is the generic form of Cardizem.

That's all pretty reasonable, right?  Except here's a copy of the script I wrote.  IT'S ALREADY WRITTEN FOR DILTIAZEM CD!!!  $@#*^!!!

I really think that these companies hire people whose only job is to sit around and figure out how to make our lives harder.

Sunday, April 15, 2012

Choose...But Choose Wisely PART 9

Yay!  The light at the end of the tunnel nears.  Tonight I can conclude this 9 part series with the American Society of Nuclear Cardiology's list.

1. Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high risk markers are present.
This has pretty much been covered, both by the ACP, the AAFP and the ACC.  If you don't believe it by now, I guess there's nothing that will convince you.

2.  Don't perform cardiac imaging for patients who are low risk.
Ditto to the above.

3.  Don't perform radionuclide imaging as routine follow up in asymptomatic patients.  
Already covered by the ACC.

4.  Don't perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low or intermediate risk surgery.
Already covered by the ACC.

5.  Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.
Always.  We always need to watch radiation exposure and aim for ALARA (as low as reasonably achievable).

That's all, folks!  More lists will be released throughout the year, and I'll be sure to review them for you!

Friday, April 13, 2012

Choose...But Choose Wisely, Part 8

On to the American Academy of Allergy, Asthma & Immunology's list.

1.  Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
There's a lot of talk out there about food allergies.  IgE- mediated food allergies are the scary kind- the kind you think about when you think of peanut allergies.  Face swelling, hives, throat closing up stuff.  Scary.  Hey, I can show you what it looks like.  My son Alex is allergic to fish, as we discovered last year when we fed him stuffed cod.  Here's a picture.  Note the swollen eyes and lips and the hives around his eyes and nose.  I think I aged about 10 years that night.

Anyway, that's an IgE-mediated food allergy.  This recommendation states that when a child has a suspected food allergy, do targeted IgE testing.  For example, Alex was tested for shellfish, crustaceans, and fin fish.  Nothing else was checked.  However, there's also a lot of talk, especially among the alternative medicine crowd, about IgG testing.  These are blood tests that claim to show sensitivities to a bunch of different foods.  I've had patients bring in blood tests results done by other practitioners that claim to show that they are allergic to literally dozens of foods.  They are basically eating brown rice and boiled chicken.  No joke.  These tests have NO evidence to support them.  None.  Don't do them, and don't get them done.

2.  Don’t order sinus computed tomography (CT) or indiscriminately
prescribe antibiotics for uncomplicated acute rhino sinusitis.
Already discussed here, but takes it one step further by reminding us that CT scans are not needed in the management of sinusitis. 

3.  Don’t routinely do diagnostic testing in patients with chronic urticaria.
Chronic urticaria is a fancy way of saying hives.  Chronic hives are miserable.  The constant itching can drive you nuts.  Hmmm...might I be speaking from personal experience?  I had hives in med school.  Luckily, they seemed to go away after a year or two.  Like most people with hives, I never figured out what caused them.  Testing is rarely helpful- time and effort should be spent on managing symptoms.

4.  Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines
are demonstrated.
Some people have an immunoglobulin deficiency, which can lead to increased susceptibility to infections.  However, low immunoglobulin levels don't always need to be treated- the levels need to be clinically significant.

5.  Don’t diagnose or manage asthma without spirometry.
 Spirometry is a test that can be done in the office.  It measures how much air is getting out of the lungs in a breath.  It's a great test to diagnose and monitor asthma, and can help guide treatment.

Wow, one list left!  Still with the weird formatting.  I should just pretend that I'm doing it intentionally.

Thursday, April 12, 2012

Choose...But Choose Wisely, Part 7

Wow, up to Part 7 today.  Up today- the American Society of Nephrology- the kidney doctors.

1.  Don’t perform routine cancer screening for dialysis patients with

limited life expectancies without signs or symptoms.
This could be a tad bit controversial.  The recommendation is that routine cancer screening (mammograms and colonoscopies, for example) not be performed in dialysis patients unless they are transplant candidates.  The reason for this is that the life expectancy of a dialysis patient is very limited, unless they will be getting a transplant.  A table of the expected remaining lifetime can be found here.  For example, the average 50 year old has 30.7 years of life remaining.  The average 50 year old on dialysis has 6.2 years of life remaining.  Looking at those statistics, it just doesn't make sense to do routine cancer screening in those cases.  I'm sure some people will read that and scream, "Rationing!" and "Death Panels!"  I suppose in a way it is rationing.  I'm not sure there's anything wrong with that.  However, that's a post for another day.

2.  Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
 This recommendation is regarding drugs that stimulate the production of red blood cells.  Many patients with kidney disease are anemic- that's because the hormone that stimulates red cell production is made in the kidneys.  In the past, ESAs were given with the goal of getting the hemoglobin to a normal range (around 12.0).  However, many studies have been done that actually show worse outcomes when the hemoglobin is "normal."  The recommendation is to not aim for a hemoglobin of greater than 10.

3.  Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with
hypertension or heart failure or CKD of all causes, including diabetes.
NSAIDS (ibuprofen, Celebrex, Mobic, naproxen, etc) are bad in people with kidney disease.  'Nuff said. 

4.  Don’t place peripherally inserted central catheters (PICC) in stage
III–V CKD patients without consulting nephrology.
A PICC is a type of IV line.  It is inserted into the arm and runs into the central veins.  It's not a good idea to put them in someone who might be needing dialysis in the near future, because it can mess up their veins and limit options for access for dialysis. 

5.  Don’t initiate chronic dialysis without ensuring a shared decision-
making process between patients, their families, and their physicians.
This one is likely to be the most controversial recommendation of all, and the one most likely to make the death panel crew pick up their pitchforks.  However, I think it's spot on.  Not every patient who has end-stage renal disease should get dialysis.  Remember that chart I showed you before?  It's here. A healthy 80 year old has an average of 8.4 years left.   A person who is a candidate for dialysis almost certainly has many other medical issues, and it's unlikely they are looking at 8.4 years- they might be looking at half of that.  The life expectancy for an 80 year old on dialysis is 2.3 years.  So, we're looking at a potential gain of perhaps 2 years, maybe a bit more or less.  Of those years, they will be in a dialysis unit for 3 to 4 hours at a time three times a week.  In 2008, one year of dialysis cost $72,000 per patient.  That's just for the dialysis, not the associated medications and treatment for other illness.  This is a big burden for patients, their families, and society- it needs to be carefully looked at.

Again with the weird formatting.  I give up.  HTML, you are my nemesis.

Wednesday, April 11, 2012

Choose...But Choose Wisely, Part 6

On to the American College of Radiology's list.

1.  Don’t do imaging for uncomplicated headache.
This means, don't get an MRI or CT scan on everyone with a run of the mill headache.  Most people with headaches don't need imaging.  There is a lot of evidence out there to support this- it's very rare that imaging will change the outcome or management of a case.  If you're interested in learning more about this, check out this article.
2.  Don’t image for suspected pulmonary embolism (PE) without moderate
or high pre-test probability. 
Already discussed here.

3.  Avoid admission or preoperative chest x-rays for ambulatory patients 
with unremarkable history and physical exam. 
Already discussed here.

4.  Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
 I'll take their word for this.   I don't practice pediatrics.  Never liked it, even in med school.  

5.  Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. 
Good one!  Everyone who ovulates gets ovarian cysts.  It's part of normal physiology.  Sometimes they cause pain and a ultrasound gets ordered.  If it's just a simple cyst, it's nothing to worry about and doesn't need to be followed up.  

I apologize for the completely bizarre formatting in this post.  I have no idea what that's about, and I'm too tired to figure it out now.

Tuesday, April 10, 2012

Choose, But Choose Wisely, Part 5

Moving on...

The list from the American Society of Clinical Oncology.

1.  Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anti- cancer treatment.
 This one is sure to be controversial.  Basically, it says that chemotherapy should not be used if there is not good evidence that it will work or if a patient has a low performance status.  When someone has cancer, especially if they are relatively young, there is often a push to "try everything."  This recommendation says not to do that- don't throw chemotherapy at people just in case it might work.  This will be a tough one for people to buy in to.

2.  Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis. 
If someone has been diagnosed with an early stage prostate cancer, there is no need for any extensive imaging.  Just treat the cancer.

3.  Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast dance at low risk for metastasis. 
Similar to above.  Please check out this excellent blog post by a cancer surgeon for more information.

4.  Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
 Again, please see this post.

5. Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication. 
There are certain medications that can be given that stimulate the production of white blood cells.  This can counteract the loss of white blood cells from chemotherapy.  However, these medications themselves carry risks and some very unpleasant side effects.  This recommendation is that these medications not be used unless the patient is at risk of complications from low white blood cells.

Sunday, April 8, 2012

Choose, But Choose Wisely, Part 4

OK, on to the list from the American College of Cardiology.

1.  Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

This recommendation is similar to the ACP's recommendation discussed here.

2.  Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
 This is a great one.  I can't tell you how many patients I see who are getting an annual stress test due to a history of coronary artery disease, even though they don't have any symptoms.  It's not necessary, not indicated, and leads to unwarranted interventions.

3.  Don’t perform stress cardiac imaging or advanced non-invasive
imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. 
Another good one, and a recommendation that, I'm glad to say, in my experience is already followed.  I usually use the ACC/AHA guidelines when I do a pre-operative assessment on a patient.  If you're interested, the complete guidelines are here.

4.  Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. 
So, people with mitral valve prolapse, a bit of aortic stenosis, etc- don't do an echocardiogram unless there is a change in the physical exam or symptoms develop.

5.  Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).
This one sounds fancy, but it's really quite simple.  When a patient has a heart attack and gets rushed to the cath lab, only the area that caused the heart attack should get a stent.  It might be tempting to put a stent in other areas that have some blockage, but if they didn't cause the heart attack, they should be left alone (as long as the patient is otherwise stable).

Friday, April 6, 2012

Choose...But Choose Wisely, Part 3

OK, moving on to the American Gastroenterological Association's list of five things that should be questioned.

1.  For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
This is a good one.  Proton pump inhibitors are Prilosec, Protonix, Nexium and the like.  Pharmaceutical companies have done a great job at turning what used to be called "heartburn" into the much scarier sounding "gastro-esophageal reflux disease."  Suddenly, everyone thinks that they HAVE to be on one of these medications, or else permanent, lasting damage will be done to their esophagus.  Don't believe me?  Before the patent on Prilosec expired, it accounted for 39% of Astra-Zeneca's revenue.  In 2009, PPI revenue for drug companies was $13.1 billion.  Yup, that's billion, with a "b".  Once patients get on these drugs, they seem to stay on them forever.  Now, we a starting to see some problems.  Long-term PPI use is associated with a higher risk of hip fracture.  Many of them interfere with other drugs.  They are also associated with a higher risk of aspiration pneumonia and c. dificile colitis.  A lot of heartburn can be cured with lifestyle changes, such as diet change and weight loss, rather than taking a pill.

2.  Do not repeat colorectal cancer screening (by any method) for 10 years
after a high-quality colonoscopy is negative in average-risk individuals.
Enough said.  Why anyone would want to have a colonoscopy more often than this is beyond me.

3.  Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high- grade dysplasia, completely removed via a high-quality colonoscopy. 
Same as above.  Even with polyps, if it is just one or two small ones, you don't need another colonoscopy before five years have passed.

4.  For a patient who is diagnosed with Barrett’s esophagus, who has
undergone a second endoscopy that confirms the absence of dysplasia
on biopsy, a follow-up surveillance examination should not be
performed in less than three years as per published guidelines.
Barrett's esophagus is a condition where there are pre-cancerous changes in cells lining the esophagus.  This recommends that follow-up in certain cases should be only every three years.

5.  For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
This is another good one. Functional abdominal pain syndrome is similar to irritable bowel syndrome, but the pain is not related to having a bowel movement or to eating.  Patients present with chronic abdominal pain.  It is a diagnosis of exclusion, meaning that other things need to be ruled out via lab tests and imaging.  However, once the diagnosis is made, further testing and imaging should be avoided.  This is important, as patients with functional abdominal pain syndrome often see multiple doctors in an attempt to find some relief.  These otherwise well-meaning doctors often order more imaging, often times because it's hard to throw up your hands and admit that there's nothing else to do.  However, repeated CT scans can increase the risk of cancer due to radiation exposure.

More to come...

Thursday, April 5, 2012

Choose...But Choose Wisely. Part Deux.

Yesterday I discussed the American College of Physicians' Choosing Wisely list- a list of five tests that should be questioned.

Today, I'll discuss the recommendations from the American Academy of Family Physicians.
1. Don’t do imaging for low back pain within the first six weeks, unless
red flags are present. 
Obviously, this is quite similar to the ACP's recommendation of not doing imaging for non-specific back pain.  What are these "red flags?"  In general, they refer to specific neurological symptoms.  Imaging of the back does not improve outcomes in routine low back pain.

2.Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
Symptoms must include discolored nasal secretions and facial or dental tenderness when touched. Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.
Read this again.  And again.  And again.  It's the truth.

3.  Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
I'll add my own, additional recommendation to this.  Don't do repeated DEXA screening on patients with normal bone density.  I read the bone density tests that are done in my hospital.  I can't believe how many people have a bone density test every two years no matter what, despite them consistently being normal and unchanged.

4.  Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

Again, similar to the ACP's recommendation to not order stress tests on low-risk patients.  This takes it a bit further and includes not doing annual ECGs, with which I whole-heartedly agree.

5.  Don’t perform Pap smears on women younger than 21 or who havehad a hysterectomy for non-cancer disease.
Yup.  Agreed.  See my blog post here.  And please, please, no more Pap smears on people without a cervix!

More to come tomorrow!

Wednesday, April 4, 2012

Choose...But Choose Wisely

I am going to write a series posts on this topic, because I think that this is one of the most important issues  addressed by national specialty societies in a long time.  Readers of this blog and my patients know that I often talk about the problems associated with over-testing.  On this blog I've discussed the issues with mammography, pap smears, PSA, and MRIs for orthopedic complaints, to name a few.

It's now nice to have some validation. Nine specialty societies have each created a list of five tests that should be questioned, rather than being ordered reflexively.  They have created an initiative called "Choosing Wisely."  I am going to address each society's list in its own post.  Keep in mind, no one is saying that these tests should NEVER be used.  They just need to be used in clinically appropriate circumstances.

Let's start with my own specialty society- the American College of Physicians.  Its list can be found here.

1.  Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary  heart disease.
Otherwise known as a "stress test."  There is no role for a "screening" stress test if you have a low risk for heart disease.  How do you know if you're low risk?  Go here.  Plug in your numbers.  If they're less than 10%, you're low risk.  Oh, and there's an app for that.  Really.

2.  Don’t obtain imaging studies in patients with non-specific low back pain.
  In other words, don't get an MRI, X-ray, or CT scan for people with back pain in the absence of certain symptoms.  It does not provide useful information or improve outcomes.  Most low back is muscular in origin- it responds to exercise, weight loss, stretching, tincture of time, and judicious use of anti-inflammatories.

3.  In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI). 
Syncope is a fancy word for fainting or "passing out."  Most syncope is vasovagal- you know, that feeling of the blood leaving your head, the world going gray, tunnel vision, and then WHAM- you hit the floor.  Lots of stuff can cause it, and very few of those things are dangerous.  It's almost never caused by a neurological issue, and there is no need for head imaging.  Even when it's caused by something bad, that something bad is usually cardiac, meaning it's caused by the heart, not the brain.

4.  In patients with low pretest probability of venous thromboembo- lism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
Hmmm.  This one requires a medical-ese to English translation, I think.  Pre-test probability = the likelihood that a person has a specific condition.  VTE = blood clot (either in the leg or as a pulmonary embolism.)  High-sensitive D-dimer measurement = a blood test for a particular protein in the blood that is elevated when there is a clot.
   This is an interesting one that I'm sure is going to instigate some debate.  There is tool called the Wells Criteria.  This takes into account various risk factors and signs and symptoms for pulmonary embolism (PE).  It allows a calculation of high, low, or medium probability of a PE.  This recommendation states that if someone has a low probability of a PE, you should do a D-dimer test rather than an imaging test (which is a CT scan of the chest) to rule out a PE.  If the D-dime test is negative, a PE is unlikely.
    While I agree with this recommendation, I can see a lot of doctors not following it.  First of all, some D-dimer assays are not that reliable, so it depends on how much faith you place in your lab's assay.  PE's can be deadly.  They can also be notoriously difficult to diagnose.  A CT angiogram is the "gold standard" to rule out a PE, but has the risk of a fairly large dose of radiation (directly to the breasts, in women).  

5.  Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. 
Hallelujah.  Now I just have to get my surgical colleagues to stop ordering them prior to surgeries!

More to follow tomorrow!