Mary Ellen Schneider

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don't really understand the underlying pathophysiology, she said. “We haven't really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren't doing a very good job of identifying children who have been exposed to secondhand smoke.

For her next project, Dr. Wilson is hoping to take her research to the cellular level—looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information might be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is one of just a small group of pediatric hospitalists doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand. “There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There's just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, she said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine. “I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions.”

Disclosures: Dr. Wilson's work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

When research is lacking, pediatric hospitalists must rely too much on case studies or 'eminence-based' medicine.

Source DR. WILSON

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don't really understand the underlying pathophysiology, she said. “We haven't really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren't doing a very good job of identifying children who have been exposed to secondhand smoke.

For her next project, Dr. Wilson is hoping to take her research to the cellular level—looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information might be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is one of just a small group of pediatric hospitalists doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand. “There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There's just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, she said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine. “I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions.”

Disclosures: Dr. Wilson's work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

When research is lacking, pediatric hospitalists must rely too much on case studies or 'eminence-based' medicine.

Source DR. WILSON

For Dr. Karen Wilson, research holds the key to improving the care of hospitalized children.

As an assistant professor of pediatric hospital medicine at the University of Rochester (N.Y.), Dr. Wilson has spent the last few years studying how secondhand smoke affects children, especially the high-risk children who end up hospitalized for respiratory illnesses.

Despite widespread recognition that secondhand smoke is bad for children, scientists don't really understand the underlying pathophysiology, she said. “We haven't really looked at what it does to kids on the cellular level, but I think that if we knew what it did to kids on [that] level there would be a lot more pressure for there to be absolutely no smoking around children ever.”

For her part, Dr. Wilson is currently collecting data on cytokine levels in healthy children. This data can later be compared with data from hospitalized children to provide evidence about the impact of secondhand smoke.

She recently completed a study looking at the effectiveness of screening children for secondhand smoke exposure in the inpatient setting. She and her colleagues compared what was documented in the chart regarding exposure, information from parent interviews, and measurements of cotinine levels in the children. They found that physicians aren't doing a very good job of identifying children who have been exposed to secondhand smoke.

For her next project, Dr. Wilson is hoping to take her research to the cellular level—looking at the cellular effects of secondhand smoke and how those changes relate to the severity of illness in hospitalized children. Once researchers have achieved a better understanding of the actual effects of secondhand smoke exposure, the information might be used to develop therapeutic interventions.

Dr. Wilson said she can envision a scenario someday when physicians could use a biochemical profile to determine whether children are at increased risk for complications from a respiratory illness.

On the policy and prevention side, Dr. Wilson said she hopes that being able to document biologic changes in children exposed to secondhand smoke will give physicians more leverage with parents and policy makers in advocating avoidance of smoking around children.

Dr. Wilson is one of just a small group of pediatric hospitalists doing research on the effects of secondhand smoke exposure. Part of the problem is that pediatric hospital medicine is a new subspecialty and there are few fellowships, particularly ones that focus on research skills. But the field is starting to expand. “There are so many important questions that need to be answered, and there are a number of people doing great work,” she said. “There's just not enough to do all the work that needs to be done at this point.”

Training a cadre of research-focused physicians in pediatric hospital medicine is essential to improving the quality of care for children, she said. Without evidence from rigorous studies, pediatric hospitalists are left to rely too heavily on case studies or “eminence-based” medicine. “I strongly believe that in order to provide the best care for children, we need to have a strong base of research that informs those decisions.”

Disclosures: Dr. Wilson's work is funded by the AAP Julius B. Richmond Center of Excellence, the Flight Attendant Medical Research Institute, and the National Institutes of Health.

When research is lacking, pediatric hospitalists must rely too much on case studies or 'eminence-based' medicine.

Source DR. WILSON

U.S. hospitals have improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report issued last month by the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 97% of the time, up from 87% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety, which also reported that in 2008, hospitals provided evidence-based heart failure care 92% of the time (up from 60% in 2002), and evidence-based pneumonia care 93% of the time in 2008 (up from 72% in 2002). (See box.)

Composite scores were calculated using data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Children's asthma care was surveyed for the first time in 2008, with two subcategories both scoring over 99%.

“This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the commission, said in an interview. For 8 of the 28 measures tracked in 2008, hospitals had consistently high performance, with about 90% of hospitals scoring 90% or more.

Dr. Loeb described hospitalists as one of the driving forces behind this success. Although there is no literature yet to back up the claim, he said he believes that in organizations with hospitalists, fewer things fall through the cracks and more attention is paid to standardization.

Dr. Loeb said the Joint Commission does not advocate “cookbook medicine.” The quality measures endorsed by the commission allow for clinical judgment, and scores do not decline when organizations deliver care that is contrary to the measures but clinically appropriate for individual patients, he said.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, hospitals in 2008 scored only 52% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Also, hospitals in 2008 scored only 60% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both measures were introduced in 2005.

In some cases it takes a few years for hospitals to make progress on a new measure. Joint Commission officials saw this with measures calling for clinicians to provide smoking cessation advice. In 2002, hospitals scored 37.2% on providing smoking cessation advice to pneumonia patients, but that number jumped to 96% in 2008.

“The learning curve in health care is lengthy,” Dr. Loeb said. “For those things that we've been measuring for a longer period of time, organizations are doing better.”

For measures related to antibiotic administration, the numbers have been slower to climb because of ongoing controversy about when antibiotics are appropriate, he added.

“Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009” is available online at www.jointcommission.org

Source ELSEVIER GLOBAL MEDICAL NEWS

U.S. hospitals have improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report issued last month by the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 97% of the time, up from 87% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety, which also reported that in 2008, hospitals provided evidence-based heart failure care 92% of the time (up from 60% in 2002), and evidence-based pneumonia care 93% of the time in 2008 (up from 72% in 2002). (See box.)

Composite scores were calculated using data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Children's asthma care was surveyed for the first time in 2008, with two subcategories both scoring over 99%.

“This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the commission, said in an interview. For 8 of the 28 measures tracked in 2008, hospitals had consistently high performance, with about 90% of hospitals scoring 90% or more.

Dr. Loeb described hospitalists as one of the driving forces behind this success. Although there is no literature yet to back up the claim, he said he believes that in organizations with hospitalists, fewer things fall through the cracks and more attention is paid to standardization.

Dr. Loeb said the Joint Commission does not advocate “cookbook medicine.” The quality measures endorsed by the commission allow for clinical judgment, and scores do not decline when organizations deliver care that is contrary to the measures but clinically appropriate for individual patients, he said.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, hospitals in 2008 scored only 52% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Also, hospitals in 2008 scored only 60% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both measures were introduced in 2005.

In some cases it takes a few years for hospitals to make progress on a new measure. Joint Commission officials saw this with measures calling for clinicians to provide smoking cessation advice. In 2002, hospitals scored 37.2% on providing smoking cessation advice to pneumonia patients, but that number jumped to 96% in 2008.

“The learning curve in health care is lengthy,” Dr. Loeb said. “For those things that we've been measuring for a longer period of time, organizations are doing better.”

For measures related to antibiotic administration, the numbers have been slower to climb because of ongoing controversy about when antibiotics are appropriate, he added.

“Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009” is available online at www.jointcommission.org

Source ELSEVIER GLOBAL MEDICAL NEWS

U.S. hospitals have improved the care they provide for patients with myocardial infarction, heart failure, and pneumonia, according to a report issued last month by the Joint Commission.

Hospitals accredited by the commission are adhering to quality measures for MI patients 97% of the time, up from 87% just 7 years earlier. The results are part of the Joint Commission's annual report on quality and safety, which also reported that in 2008, hospitals provided evidence-based heart failure care 92% of the time (up from 60% in 2002), and evidence-based pneumonia care 93% of the time in 2008 (up from 72% in 2002). (See box.)

Composite scores were calculated using data drawn from all Joint Commission–accredited hospitals between 2002 and 2008. Children's asthma care was surveyed for the first time in 2008, with two subcategories both scoring over 99%.

“This improvement translates into significant enhancements in terms of morbidity and mortality across the conditions that we're measuring,” Jerod M. Loeb, Ph.D., executive vice president for quality measurement and research at the commission, said in an interview. For 8 of the 28 measures tracked in 2008, hospitals had consistently high performance, with about 90% of hospitals scoring 90% or more.

Dr. Loeb described hospitalists as one of the driving forces behind this success. Although there is no literature yet to back up the claim, he said he believes that in organizations with hospitalists, fewer things fall through the cracks and more attention is paid to standardization.

Dr. Loeb said the Joint Commission does not advocate “cookbook medicine.” The quality measures endorsed by the commission allow for clinical judgment, and scores do not decline when organizations deliver care that is contrary to the measures but clinically appropriate for individual patients, he said.

Despite the successes documented in the report, hospitals are still struggling on a few measures. For example, hospitals in 2008 scored only 52% on providing fibrinolytic therapy to heart attack patients within 30 minutes of arrival. Also, hospitals in 2008 scored only 60% on providing antibiotics to ICU pneumonia patients within 24 hours of arrival. Both measures were introduced in 2005.

In some cases it takes a few years for hospitals to make progress on a new measure. Joint Commission officials saw this with measures calling for clinicians to provide smoking cessation advice. In 2002, hospitals scored 37.2% on providing smoking cessation advice to pneumonia patients, but that number jumped to 96% in 2008.

“The learning curve in health care is lengthy,” Dr. Loeb said. “For those things that we've been measuring for a longer period of time, organizations are doing better.”

For measures related to antibiotic administration, the numbers have been slower to climb because of ongoing controversy about when antibiotics are appropriate, he added.

“Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009” is available online at www.jointcommission.org

Source ELSEVIER GLOBAL MEDICAL NEWS

Health care spending in the United States grew less than 5% in 2008, the slowest rate of growth since the federal government officially began measuring it in 1960, according to a new report from the Centers for Medicare and Medicaid Services.

But the figures show that even though the rate of increase is slower than in previous years, health care spending is still outpacing gross domestic product. In 2008, health care spending rose 4.4% to $2.3 trillion, compared with only a 2.8% increase in the GDP. And health spending continues to consume a larger portion of the overall GDP, taking up 16.2% of GDP in 2008, compared with 15.9% in 2007 (Health Affairs 2010;29:147-55).

The overall slowdown in health spending growth is reflected in slower rates of increase in hospital spending, physician services spending, retail prescription drug spending, and spending for nursing home and home health services.

For example, spending on physician and clinical services increased 5% in 2008, down from 5.8% in 2007. The deceleration in physician services was driven by a decrease in patient volume, even as the intensity of services picked up in 2008.

During a teleconference, Rick Foster, CMS chief actuary, speculated that this trend was mainly due to the recession. As people lost jobs and health insurance in 2008, they may have opted to seek health care only when their conditions became more serious, and more costly to treat, he said.

The share of federal dollars spent on health care rose from 28% in 2007 to nearly 36% in 2008, according to the CMS.

Health care spending in the United States grew less than 5% in 2008, the slowest rate of growth since the federal government officially began measuring it in 1960, according to a new report from the Centers for Medicare and Medicaid Services.

But the figures show that even though the rate of increase is slower than in previous years, health care spending is still outpacing gross domestic product. In 2008, health care spending rose 4.4% to $2.3 trillion, compared with only a 2.8% increase in the GDP. And health spending continues to consume a larger portion of the overall GDP, taking up 16.2% of GDP in 2008, compared with 15.9% in 2007 (Health Affairs 2010;29:147-55).

The overall slowdown in health spending growth is reflected in slower rates of increase in hospital spending, physician services spending, retail prescription drug spending, and spending for nursing home and home health services.

For example, spending on physician and clinical services increased 5% in 2008, down from 5.8% in 2007. The deceleration in physician services was driven by a decrease in patient volume, even as the intensity of services picked up in 2008.

During a teleconference, Rick Foster, CMS chief actuary, speculated that this trend was mainly due to the recession. As people lost jobs and health insurance in 2008, they may have opted to seek health care only when their conditions became more serious, and more costly to treat, he said.

The share of federal dollars spent on health care rose from 28% in 2007 to nearly 36% in 2008, according to the CMS.

Health care spending in the United States grew less than 5% in 2008, the slowest rate of growth since the federal government officially began measuring it in 1960, according to a new report from the Centers for Medicare and Medicaid Services.

But the figures show that even though the rate of increase is slower than in previous years, health care spending is still outpacing gross domestic product. In 2008, health care spending rose 4.4% to $2.3 trillion, compared with only a 2.8% increase in the GDP. And health spending continues to consume a larger portion of the overall GDP, taking up 16.2% of GDP in 2008, compared with 15.9% in 2007 (Health Affairs 2010;29:147-55).

The overall slowdown in health spending growth is reflected in slower rates of increase in hospital spending, physician services spending, retail prescription drug spending, and spending for nursing home and home health services.

For example, spending on physician and clinical services increased 5% in 2008, down from 5.8% in 2007. The deceleration in physician services was driven by a decrease in patient volume, even as the intensity of services picked up in 2008.

During a teleconference, Rick Foster, CMS chief actuary, speculated that this trend was mainly due to the recession. As people lost jobs and health insurance in 2008, they may have opted to seek health care only when their conditions became more serious, and more costly to treat, he said.

The share of federal dollars spent on health care rose from 28% in 2007 to nearly 36% in 2008, according to the CMS.

New Jersey has become the 14th state in the nation to allow the medical use of marijuana, although its program will be the country's most restrictive.

Outgoing Gov. Jon S. Corzine (D) signed the “Compassionate Use Medical Marijuana Act” into law on Jan. 18, shortly before leaving office; the law will take effect in 6 months. The new law will remove legal penalties for the possession and use of marijuana for medical purposes. Under the law, the drug must be recommended by a licensed state physician for a qualifying medical condition such as cancer, HIV/AIDS, multiple sclerosis, amyotrophic lateral sclerosis, or Crohn's disease.

The program is expected to be tightly regulated by the state Department of Health, and patients who wish to obtain medical marijuana will be issued identification cards. Marijuana for medical use will be dispensed at Alternative Treatment Centers around the state, which will also be regulated by the state. Unlike other state medical marijuana laws, the New Jersey bill prohibits the cultivation of marijuana at home.

The enactment of the New Jersey law was applauded by advocates of medical marijuana. Ken Wolski, R.N., executive director of the Coalition for Medical Marijuana–New Jersey, said it was a significant step forward for patients in the state.

But he said the new law is too restrictive. For example, the group had urged legislators to allow at-home cultivation of marijuana, but such a provision was stripped from the bill. Mr. Wolski said the list of qualifying medical conditions also is too narrow, leaving marijuana available to only a fraction of the patients who could potentially benefit.

But he praised the new system of alternative treatment centers that will be set up to dispense marijuana under the bill. Mr. Wolski said these dispensaries will be tightly regulated and should mimic the pharmaceutical distribution system.

“This may very well be a model for the rest of the country or for the nation moving forward,” he said.

Dr. Nathan Wei, a rheumatologist in Frederick, Md., agreed that the restrictive nature of the New Jersey law might be exactly what makes it appealing as a model for other states.

“People don't want to become another California,” Dr. Wei said. New Jersey's legislature has “created a legalization model that I think most people could live with.”

The developments in New Jersey come as the use of marijuana as a medicine seems to be gaining some legal and political traction.

Since 1996, 13 other states have enacted laws that allow for some type of medical use of marijuana. In November 2009, the American Medical Association approved a new policy recommending that the federal government review its classification of marijuana with the goal of making research into cannabinoid-based medicines easier.

Also last fall, the Justice Department weighed in on medical marijuana in a memo to federal prosecutors. The memo effectively told federal prosecutors in states with laws authorizing the medical use of marijuana not to waste time enforcing the federal prohibition on marijuana.

The prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” the memo said.

In a February 2009 position paper, the American College of Physicians backed “rigorous scientific evaluation of the potential therapeutic benefits of medical marijuana” and stated that physicians who prescribe or dispense medical marijuana and patients who use it in accordance with state law should be shielded from federal criminal prosecution.

The ACP also urged review of marijuana's status as a schedule I controlled substance “and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana's safety and efficacy in some clinical conditions.”

New Jersey has become the 14th state in the nation to allow the medical use of marijuana, although its program will be the country's most restrictive.

Outgoing Gov. Jon S. Corzine (D) signed the “Compassionate Use Medical Marijuana Act” into law on Jan. 18, shortly before leaving office; the law will take effect in 6 months. The new law will remove legal penalties for the possession and use of marijuana for medical purposes. Under the law, the drug must be recommended by a licensed state physician for a qualifying medical condition such as cancer, HIV/AIDS, multiple sclerosis, amyotrophic lateral sclerosis, or Crohn's disease.

The program is expected to be tightly regulated by the state Department of Health, and patients who wish to obtain medical marijuana will be issued identification cards. Marijuana for medical use will be dispensed at Alternative Treatment Centers around the state, which will also be regulated by the state. Unlike other state medical marijuana laws, the New Jersey bill prohibits the cultivation of marijuana at home.

The enactment of the New Jersey law was applauded by advocates of medical marijuana. Ken Wolski, R.N., executive director of the Coalition for Medical Marijuana–New Jersey, said it was a significant step forward for patients in the state.

But he said the new law is too restrictive. For example, the group had urged legislators to allow at-home cultivation of marijuana, but such a provision was stripped from the bill. Mr. Wolski said the list of qualifying medical conditions also is too narrow, leaving marijuana available to only a fraction of the patients who could potentially benefit.

But he praised the new system of alternative treatment centers that will be set up to dispense marijuana under the bill. Mr. Wolski said these dispensaries will be tightly regulated and should mimic the pharmaceutical distribution system.

“This may very well be a model for the rest of the country or for the nation moving forward,” he said.

Dr. Nathan Wei, a rheumatologist in Frederick, Md., agreed that the restrictive nature of the New Jersey law might be exactly what makes it appealing as a model for other states.

“People don't want to become another California,” Dr. Wei said. New Jersey's legislature has “created a legalization model that I think most people could live with.”

The developments in New Jersey come as the use of marijuana as a medicine seems to be gaining some legal and political traction.

Since 1996, 13 other states have enacted laws that allow for some type of medical use of marijuana. In November 2009, the American Medical Association approved a new policy recommending that the federal government review its classification of marijuana with the goal of making research into cannabinoid-based medicines easier.

Also last fall, the Justice Department weighed in on medical marijuana in a memo to federal prosecutors. The memo effectively told federal prosecutors in states with laws authorizing the medical use of marijuana not to waste time enforcing the federal prohibition on marijuana.

The prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” the memo said.

In a February 2009 position paper, the American College of Physicians backed “rigorous scientific evaluation of the potential therapeutic benefits of medical marijuana” and stated that physicians who prescribe or dispense medical marijuana and patients who use it in accordance with state law should be shielded from federal criminal prosecution.

The ACP also urged review of marijuana's status as a schedule I controlled substance “and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana's safety and efficacy in some clinical conditions.”

New Jersey has become the 14th state in the nation to allow the medical use of marijuana, although its program will be the country's most restrictive.

Outgoing Gov. Jon S. Corzine (D) signed the “Compassionate Use Medical Marijuana Act” into law on Jan. 18, shortly before leaving office; the law will take effect in 6 months. The new law will remove legal penalties for the possession and use of marijuana for medical purposes. Under the law, the drug must be recommended by a licensed state physician for a qualifying medical condition such as cancer, HIV/AIDS, multiple sclerosis, amyotrophic lateral sclerosis, or Crohn's disease.

The program is expected to be tightly regulated by the state Department of Health, and patients who wish to obtain medical marijuana will be issued identification cards. Marijuana for medical use will be dispensed at Alternative Treatment Centers around the state, which will also be regulated by the state. Unlike other state medical marijuana laws, the New Jersey bill prohibits the cultivation of marijuana at home.

The enactment of the New Jersey law was applauded by advocates of medical marijuana. Ken Wolski, R.N., executive director of the Coalition for Medical Marijuana–New Jersey, said it was a significant step forward for patients in the state.

But he said the new law is too restrictive. For example, the group had urged legislators to allow at-home cultivation of marijuana, but such a provision was stripped from the bill. Mr. Wolski said the list of qualifying medical conditions also is too narrow, leaving marijuana available to only a fraction of the patients who could potentially benefit.

But he praised the new system of alternative treatment centers that will be set up to dispense marijuana under the bill. Mr. Wolski said these dispensaries will be tightly regulated and should mimic the pharmaceutical distribution system.

“This may very well be a model for the rest of the country or for the nation moving forward,” he said.

Dr. Nathan Wei, a rheumatologist in Frederick, Md., agreed that the restrictive nature of the New Jersey law might be exactly what makes it appealing as a model for other states.

“People don't want to become another California,” Dr. Wei said. New Jersey's legislature has “created a legalization model that I think most people could live with.”

The developments in New Jersey come as the use of marijuana as a medicine seems to be gaining some legal and political traction.

Since 1996, 13 other states have enacted laws that allow for some type of medical use of marijuana. In November 2009, the American Medical Association approved a new policy recommending that the federal government review its classification of marijuana with the goal of making research into cannabinoid-based medicines easier.

Also last fall, the Justice Department weighed in on medical marijuana in a memo to federal prosecutors. The memo effectively told federal prosecutors in states with laws authorizing the medical use of marijuana not to waste time enforcing the federal prohibition on marijuana.

The prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” the memo said.

In a February 2009 position paper, the American College of Physicians backed “rigorous scientific evaluation of the potential therapeutic benefits of medical marijuana” and stated that physicians who prescribe or dispense medical marijuana and patients who use it in accordance with state law should be shielded from federal criminal prosecution.

The ACP also urged review of marijuana's status as a schedule I controlled substance “and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana's safety and efficacy in some clinical conditions.”

BOSTON — Struggling to help your diabetic patients stay in control?

The answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, physicians generally assess the patient and give out instructions. But diabetes is a self-management disease that requires patients to change their behavior, something that isn't likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence is in the U.S. statistics on diabetes: Less than half of diabetic patients achieve recommended hemoglobin A_1c goals, and about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2½ hours.

During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with hemoglobin A_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions. Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. The sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

Each visit has a set topic, and patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” Dr. Shahady said. This interaction is much more effective than getting suggestions from the physician, he added.

If a patient gets emotional, ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Groups should be kept to about 10 patients. Most of the members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they can offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

Dr. Shahady has developed an 18-page manual with instructions on how to set up group visits for diabetes, including sample documents. The manual is available online at http://www.fafp.org/PDF_Diabetes/P2%20Group%20visit%20focus%20on%20diabetes.pdf

BOSTON — Struggling to help your diabetic patients stay in control?

The answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, physicians generally assess the patient and give out instructions. But diabetes is a self-management disease that requires patients to change their behavior, something that isn't likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence is in the U.S. statistics on diabetes: Less than half of diabetic patients achieve recommended hemoglobin A_1c goals, and about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2½ hours.

During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with hemoglobin A_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions. Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. The sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

Each visit has a set topic, and patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” Dr. Shahady said. This interaction is much more effective than getting suggestions from the physician, he added.

If a patient gets emotional, ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Groups should be kept to about 10 patients. Most of the members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they can offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

Dr. Shahady has developed an 18-page manual with instructions on how to set up group visits for diabetes, including sample documents. The manual is available online at http://www.fafp.org/PDF_Diabetes/P2%20Group%20visit%20focus%20on%20diabetes.pdf

BOSTON — Struggling to help your diabetic patients stay in control?

The answer may be to get those patients together for a group visit, said Dr. Edward Shahady, medical director of the Diabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville.

During a traditional one-on-one office visit, physicians generally assess the patient and give out instructions. But diabetes is a self-management disease that requires patients to change their behavior, something that isn't likely to happen based solely on advice received during an office visit, Dr. Shahady said at the annual meeting of the American Academy of Family Physicians.

The evidence is in the U.S. statistics on diabetes: Less than half of diabetic patients achieve recommended hemoglobin A_1c goals, and about a third reach their LDL cholesterol and blood pressure goals. “Just the simple office visit is not working,” he said.

Dr. Shahady and his colleagues at the foundation have developed a model for group visits that has improved satisfaction among diabetic patients, while allowing physicians to get paid for seeing complex patients.

Under the model, visits can occur every month to every 3 months with the same group of patients. The group visit may replace some of the routine diabetes visits and last about 2½ hours.

During the first hour, a nurse or medical assistant takes vital signs, helps patients complete questionnaires and other forms, and provides individual “report cards” with hemoglobin A_1c levels and other clinical values. The nurse then gets the conversation started on the visit topic, which may be on some aspect of nutrition, exercise, foot care, or lipids.

The nurse also fields questions. Dr. Shahady recommends that practices use a “parking lot” sheet to keep questions unrelated to diabetes from taking up time in the group discussion. The sheet lets patients know that their questions are important, but that the group visit is for discussing their diabetes, he said. The physician can get to those questions at the end of the session or address them later during individual office visits.

During the second hour, a physician, nurse practitioner, or physician assistant joins the group to reinforce the curriculum point for the day. Leave extra time at the beginning and end of the group visit for checking in, filling out paperwork, and writing prescriptions, he advised.

Each visit has a set topic, and patients should drive the conversation. This group dynamic can have a huge impact. If one patient admits to having difficulty finding time to exercise, other members may have valuable suggestions about how they fit exercise into their schedules. “Patients like to share solutions with each other,” Dr. Shahady said. This interaction is much more effective than getting suggestions from the physician, he added.

If a patient gets emotional, ask the group if anyone else feels the same way. The other patients generally jump in with their thoughts and advice.

Groups should be kept to about 10 patients. Most of the members should be patients whose diabetes is not well controlled, since they will benefit the most. But it's also valuable to include a couple of patients who are in good control, since they can offer advice to other group members.

If properly documented, most group visits will qualify for billing with a 99214 code, Dr. Shahady said. It's not necessary to conduct a physical exam to use the 99213 or 99214 codes for established patients. Clinicians need only collect vital signs, provided that they have already satisfied the history and level of complexity requirements. The ICD-9 code should reflect the level of control, the type of diabetes, and any complications.

Dr. Shahady has developed an 18-page manual with instructions on how to set up group visits for diabetes, including sample documents. The manual is available online at http://www.fafp.org/PDF_Diabetes/P2%20Group%20visit%20focus%20on%20diabetes.pdf

Embryo 'Adoption' Called Misleading

Using the term adoption rather than donation of embryos is misleading, inaccurate, and potentially harmful to infertile patients, according to a new report from the ethics committee of the American Society for Reproductive Medicine. While embryos should be given “elevated moral status,” compared with other human tissues, they should not be equated with persons, the committee said. Currently, the Food and Drug Administration regulates embryo donation the same way it does other human-tissue donations. Were the process regulated more like the adoption of a child, it would probably entail home visits, legal fees, and judicial review. The committee determined that such requirements are unethical burdens on infertile patients seeking embryos. “We have long had guidelines on embryo donation that address the clinical aspects of the process,” Dr. William Gibbons, the society's president, said in a statement. “This report simply clarifies that embryo donation is in fact a clinical process and should be treated as such.” The report was published in the December issue of Fertility and Sterility (Fertil. Steril. 2009;92:1818-9).

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. However, researchers can not offer payments for donation and they must obtain informed consent at the time a donors release the embryos. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Mastectomy Costs Rising Quickly

The costs for mastectomy in the United States rose 24% between 2004 and 2007, to $660 million, making it one of the 10 procedures experiencing the most rapid cost increases during that time, according to the Agency for Healthcare Research and Quality. Agency researchers also found that hospital stays for mastectomies increased only 3.6% during those years. The main driver of the cost increase is the growth in the mean cost per stay for the procedure, according to the agency's report. The other procedures experiencing the most rapid cost increases were bone marrow transplant; open prostatectomy; aortic resection, replacement, or anastomosis; cancer chemotherapy; spinal fusion; lobectomy or pneumonectomy; incision and drainage of skin and other tissues; knee arthroplasty; and nephrotomy and nephrostomy.

Medicare Covers HIV Screening

Medicare patients will now be able to get HIV screening tests as covered benefits. In December, the Centers for Medicare and Medicaid Services added HIV testing to the approved list of preventive services. “Every adult should know their HIV status,” Dr. Howard K. Koh, assistant secretary for health at the Department of Health and Human Services, said in a statement. Under the Medicare Improvements for Patients and Provider Act, passed in 2008, a preventive service must have been recommended by the U.S. Preventive Services Task Force to make Medicare's coverage list.

Adverse Event Reports Go Unused

The Food and Drug Administration's Center for Devices and Radiological Health fails to use adverse event reports in a systematic manner to detect and address medical device safety problems, a report from the HHS Office of the Inspector General found. Manufacturers and medical facilities are required to promptly submit reports to the FDA center following adverse events, which can include deaths, serious injuries, and device malfunctions. But the center has no documentation of following up on these events, and it fails to read most reports in a timely fashion, according to the report. Meanwhile, reports of problems with medical devices are increasing, the Inspector General's office found: The FDA center received about 73,000 adverse event reports in 2003 but more than 150,000 in 2007. The Inspector General recommended that the center develop better protocols for reviewing and tracking the reports.

Provider Fraud Most Common

By far, most health care fraud (80%) involves providers' systematically overcharging public or private insurers, according to a report from researchers at George Washington University, Washington, and the National Academy for State Health Policy. The study found that these schemes disproportionately target demographic groups who are likely to be enrolled in Medicare and Medicaid. However, the study found that fraud information on the public programs is frequently confused with payment-error data. The authors recommended stronger laws governing insurance marketing, enrollment, claims payments, and antifraud procedures.

Embryo 'Adoption' Called Misleading

Using the term adoption rather than donation of embryos is misleading, inaccurate, and potentially harmful to infertile patients, according to a new report from the ethics committee of the American Society for Reproductive Medicine. While embryos should be given “elevated moral status,” compared with other human tissues, they should not be equated with persons, the committee said. Currently, the Food and Drug Administration regulates embryo donation the same way it does other human-tissue donations. Were the process regulated more like the adoption of a child, it would probably entail home visits, legal fees, and judicial review. The committee determined that such requirements are unethical burdens on infertile patients seeking embryos. “We have long had guidelines on embryo donation that address the clinical aspects of the process,” Dr. William Gibbons, the society's president, said in a statement. “This report simply clarifies that embryo donation is in fact a clinical process and should be treated as such.” The report was published in the December issue of Fertility and Sterility (Fertil. Steril. 2009;92:1818-9).

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. However, researchers can not offer payments for donation and they must obtain informed consent at the time a donors release the embryos. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Mastectomy Costs Rising Quickly

The costs for mastectomy in the United States rose 24% between 2004 and 2007, to $660 million, making it one of the 10 procedures experiencing the most rapid cost increases during that time, according to the Agency for Healthcare Research and Quality. Agency researchers also found that hospital stays for mastectomies increased only 3.6% during those years. The main driver of the cost increase is the growth in the mean cost per stay for the procedure, according to the agency's report. The other procedures experiencing the most rapid cost increases were bone marrow transplant; open prostatectomy; aortic resection, replacement, or anastomosis; cancer chemotherapy; spinal fusion; lobectomy or pneumonectomy; incision and drainage of skin and other tissues; knee arthroplasty; and nephrotomy and nephrostomy.

Medicare Covers HIV Screening

Medicare patients will now be able to get HIV screening tests as covered benefits. In December, the Centers for Medicare and Medicaid Services added HIV testing to the approved list of preventive services. “Every adult should know their HIV status,” Dr. Howard K. Koh, assistant secretary for health at the Department of Health and Human Services, said in a statement. Under the Medicare Improvements for Patients and Provider Act, passed in 2008, a preventive service must have been recommended by the U.S. Preventive Services Task Force to make Medicare's coverage list.

Adverse Event Reports Go Unused

The Food and Drug Administration's Center for Devices and Radiological Health fails to use adverse event reports in a systematic manner to detect and address medical device safety problems, a report from the HHS Office of the Inspector General found. Manufacturers and medical facilities are required to promptly submit reports to the FDA center following adverse events, which can include deaths, serious injuries, and device malfunctions. But the center has no documentation of following up on these events, and it fails to read most reports in a timely fashion, according to the report. Meanwhile, reports of problems with medical devices are increasing, the Inspector General's office found: The FDA center received about 73,000 adverse event reports in 2003 but more than 150,000 in 2007. The Inspector General recommended that the center develop better protocols for reviewing and tracking the reports.

Provider Fraud Most Common

By far, most health care fraud (80%) involves providers' systematically overcharging public or private insurers, according to a report from researchers at George Washington University, Washington, and the National Academy for State Health Policy. The study found that these schemes disproportionately target demographic groups who are likely to be enrolled in Medicare and Medicaid. However, the study found that fraud information on the public programs is frequently confused with payment-error data. The authors recommended stronger laws governing insurance marketing, enrollment, claims payments, and antifraud procedures.

Embryo 'Adoption' Called Misleading

Using the term adoption rather than donation of embryos is misleading, inaccurate, and potentially harmful to infertile patients, according to a new report from the ethics committee of the American Society for Reproductive Medicine. While embryos should be given “elevated moral status,” compared with other human tissues, they should not be equated with persons, the committee said. Currently, the Food and Drug Administration regulates embryo donation the same way it does other human-tissue donations. Were the process regulated more like the adoption of a child, it would probably entail home visits, legal fees, and judicial review. The committee determined that such requirements are unethical burdens on infertile patients seeking embryos. “We have long had guidelines on embryo donation that address the clinical aspects of the process,” Dr. William Gibbons, the society's president, said in a statement. “This report simply clarifies that embryo donation is in fact a clinical process and should be treated as such.” The report was published in the December issue of Fertility and Sterility (Fertil. Steril. 2009;92:1818-9).

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. However, researchers can not offer payments for donation and they must obtain informed consent at the time a donors release the embryos. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Mastectomy Costs Rising Quickly

The costs for mastectomy in the United States rose 24% between 2004 and 2007, to $660 million, making it one of the 10 procedures experiencing the most rapid cost increases during that time, according to the Agency for Healthcare Research and Quality. Agency researchers also found that hospital stays for mastectomies increased only 3.6% during those years. The main driver of the cost increase is the growth in the mean cost per stay for the procedure, according to the agency's report. The other procedures experiencing the most rapid cost increases were bone marrow transplant; open prostatectomy; aortic resection, replacement, or anastomosis; cancer chemotherapy; spinal fusion; lobectomy or pneumonectomy; incision and drainage of skin and other tissues; knee arthroplasty; and nephrotomy and nephrostomy.

Medicare Covers HIV Screening

Medicare patients will now be able to get HIV screening tests as covered benefits. In December, the Centers for Medicare and Medicaid Services added HIV testing to the approved list of preventive services. “Every adult should know their HIV status,” Dr. Howard K. Koh, assistant secretary for health at the Department of Health and Human Services, said in a statement. Under the Medicare Improvements for Patients and Provider Act, passed in 2008, a preventive service must have been recommended by the U.S. Preventive Services Task Force to make Medicare's coverage list.

Adverse Event Reports Go Unused

The Food and Drug Administration's Center for Devices and Radiological Health fails to use adverse event reports in a systematic manner to detect and address medical device safety problems, a report from the HHS Office of the Inspector General found. Manufacturers and medical facilities are required to promptly submit reports to the FDA center following adverse events, which can include deaths, serious injuries, and device malfunctions. But the center has no documentation of following up on these events, and it fails to read most reports in a timely fashion, according to the report. Meanwhile, reports of problems with medical devices are increasing, the Inspector General's office found: The FDA center received about 73,000 adverse event reports in 2003 but more than 150,000 in 2007. The Inspector General recommended that the center develop better protocols for reviewing and tracking the reports.

Provider Fraud Most Common

By far, most health care fraud (80%) involves providers' systematically overcharging public or private insurers, according to a report from researchers at George Washington University, Washington, and the National Academy for State Health Policy. The study found that these schemes disproportionately target demographic groups who are likely to be enrolled in Medicare and Medicaid. However, the study found that fraud information on the public programs is frequently confused with payment-error data. The authors recommended stronger laws governing insurance marketing, enrollment, claims payments, and antifraud procedures.

Bioequivalence for Epilepsy Drugs

As part of the 2010 FDA appropriations law, Food and Drug Administration officials have until Sept. 30, 2010, to determine whether to change the way antiepileptic drugs are tested for bioequivalence. The agency also must report on adverse events and seizures associated with brand and generic antiepileptic drugs. Earlier this year, the Epilepsy Foundation released survey results showing that patients risked worsening seizures and other side effects when they switched their antiepileptic medications brand to generic, generic to brand, or generic to generic.

Telestroke Network Launched

North Carolina stroke patients now have access to expert physicians through a new telestroke network launched by the Comprehensive Stroke Center at Wake Forest University Baptist Medical Center in Winston-Salem. The program, which began late last year, uses a telemedicine robotic system to link rural emergency department physicians with five neurologists who are available around the clock. All of the neurologists who participate in the program have either completed fellowship training in the care of stroke patients or are board-certified in vascular neurology, according to Wake Forest University. “The Telestroke network is a real step forward in providing the latest in stroke care and expertise to all patients in North Carolina,” Dr. Charles Tegeler, director of the Comprehensive Stroke Center at Wake Forest, said in a statement.

ALS Service Connection Finalized

Officials at the Department of Veterans Affairs officially established a presumption of service connection for any veteran who develops amyotrophic lateral sclerosis (ALS) at any time after serving in the military. The policy change will make it easier for veterans with ALS to access benefits and medical care. The VA published a final rule on Nov. 4, which went into effect on that date and applies to all applications for benefits received by the VA on or after Sept. 23, 2008. In order to qualify for service connection, veterans must have 90 days or more of continuous active service in the military. VA officials based their decision to establish a service presumption for ALS on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.”

New AAN Subspecialty Forums

The American Academy of Neurology is expanding its portfolio by providing new forums for neurologists interested in hospital-based neurology care and sports neurology. The new section on neurohospitalists will focus on improving inpatient neurology care and developing future educational programs. It's also an opportunity for neurohospitalists, those hospital-based neurologists who spend at least a quarter of their time caring for inpatients, to network. “The demand for timely neurological evaluation and intervention has dramatically increased over time. In addition, financial pressures … have made it difficult for many neurologists to maintain both an inpatient and outpatient practice,” Dr. David J. Likosky, the neurohospitalist section chair, said in a statement. In the Sports Neurology section, members can stay current on evolving sports neurology topics and promote the field of sports neurology, according to the AAN.

MDA Honors Top Neurologist

Dr. Lewis “Bud” Rowland has become the first physician to earn the Muscular Dystrophy Association's Directors' Award. Dr. Rowland, who chaired the neurology department at Columbia University 1973–1998 and continues to teach there, was honored for his research in muscle and nerve physiology, and several neuromuscular conditions. Dr. R. Rodney Howell of the MDA called Dr. Rowland “the gold standard for outstanding patient care, exceptional research, and tireless leadership in the field of neuromuscular disease.”

Bioequivalence for Epilepsy Drugs

As part of the 2010 FDA appropriations law, Food and Drug Administration officials have until Sept. 30, 2010, to determine whether to change the way antiepileptic drugs are tested for bioequivalence. The agency also must report on adverse events and seizures associated with brand and generic antiepileptic drugs. Earlier this year, the Epilepsy Foundation released survey results showing that patients risked worsening seizures and other side effects when they switched their antiepileptic medications brand to generic, generic to brand, or generic to generic.

Telestroke Network Launched

North Carolina stroke patients now have access to expert physicians through a new telestroke network launched by the Comprehensive Stroke Center at Wake Forest University Baptist Medical Center in Winston-Salem. The program, which began late last year, uses a telemedicine robotic system to link rural emergency department physicians with five neurologists who are available around the clock. All of the neurologists who participate in the program have either completed fellowship training in the care of stroke patients or are board-certified in vascular neurology, according to Wake Forest University. “The Telestroke network is a real step forward in providing the latest in stroke care and expertise to all patients in North Carolina,” Dr. Charles Tegeler, director of the Comprehensive Stroke Center at Wake Forest, said in a statement.

ALS Service Connection Finalized

Officials at the Department of Veterans Affairs officially established a presumption of service connection for any veteran who develops amyotrophic lateral sclerosis (ALS) at any time after serving in the military. The policy change will make it easier for veterans with ALS to access benefits and medical care. The VA published a final rule on Nov. 4, which went into effect on that date and applies to all applications for benefits received by the VA on or after Sept. 23, 2008. In order to qualify for service connection, veterans must have 90 days or more of continuous active service in the military. VA officials based their decision to establish a service presumption for ALS on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.”

New AAN Subspecialty Forums

The American Academy of Neurology is expanding its portfolio by providing new forums for neurologists interested in hospital-based neurology care and sports neurology. The new section on neurohospitalists will focus on improving inpatient neurology care and developing future educational programs. It's also an opportunity for neurohospitalists, those hospital-based neurologists who spend at least a quarter of their time caring for inpatients, to network. “The demand for timely neurological evaluation and intervention has dramatically increased over time. In addition, financial pressures … have made it difficult for many neurologists to maintain both an inpatient and outpatient practice,” Dr. David J. Likosky, the neurohospitalist section chair, said in a statement. In the Sports Neurology section, members can stay current on evolving sports neurology topics and promote the field of sports neurology, according to the AAN.

MDA Honors Top Neurologist

Dr. Lewis “Bud” Rowland has become the first physician to earn the Muscular Dystrophy Association's Directors' Award. Dr. Rowland, who chaired the neurology department at Columbia University 1973–1998 and continues to teach there, was honored for his research in muscle and nerve physiology, and several neuromuscular conditions. Dr. R. Rodney Howell of the MDA called Dr. Rowland “the gold standard for outstanding patient care, exceptional research, and tireless leadership in the field of neuromuscular disease.”

Bioequivalence for Epilepsy Drugs

As part of the 2010 FDA appropriations law, Food and Drug Administration officials have until Sept. 30, 2010, to determine whether to change the way antiepileptic drugs are tested for bioequivalence. The agency also must report on adverse events and seizures associated with brand and generic antiepileptic drugs. Earlier this year, the Epilepsy Foundation released survey results showing that patients risked worsening seizures and other side effects when they switched their antiepileptic medications brand to generic, generic to brand, or generic to generic.

Telestroke Network Launched

North Carolina stroke patients now have access to expert physicians through a new telestroke network launched by the Comprehensive Stroke Center at Wake Forest University Baptist Medical Center in Winston-Salem. The program, which began late last year, uses a telemedicine robotic system to link rural emergency department physicians with five neurologists who are available around the clock. All of the neurologists who participate in the program have either completed fellowship training in the care of stroke patients or are board-certified in vascular neurology, according to Wake Forest University. “The Telestroke network is a real step forward in providing the latest in stroke care and expertise to all patients in North Carolina,” Dr. Charles Tegeler, director of the Comprehensive Stroke Center at Wake Forest, said in a statement.

ALS Service Connection Finalized

Officials at the Department of Veterans Affairs officially established a presumption of service connection for any veteran who develops amyotrophic lateral sclerosis (ALS) at any time after serving in the military. The policy change will make it easier for veterans with ALS to access benefits and medical care. The VA published a final rule on Nov. 4, which went into effect on that date and applies to all applications for benefits received by the VA on or after Sept. 23, 2008. In order to qualify for service connection, veterans must have 90 days or more of continuous active service in the military. VA officials based their decision to establish a service presumption for ALS on a November 2006 report from the Institute of Medicine that concluded that “there is limited and suggestive evidence of an association between military service and later development of ALS.”

New AAN Subspecialty Forums

The American Academy of Neurology is expanding its portfolio by providing new forums for neurologists interested in hospital-based neurology care and sports neurology. The new section on neurohospitalists will focus on improving inpatient neurology care and developing future educational programs. It's also an opportunity for neurohospitalists, those hospital-based neurologists who spend at least a quarter of their time caring for inpatients, to network. “The demand for timely neurological evaluation and intervention has dramatically increased over time. In addition, financial pressures … have made it difficult for many neurologists to maintain both an inpatient and outpatient practice,” Dr. David J. Likosky, the neurohospitalist section chair, said in a statement. In the Sports Neurology section, members can stay current on evolving sports neurology topics and promote the field of sports neurology, according to the AAN.

MDA Honors Top Neurologist

Dr. Lewis “Bud” Rowland has become the first physician to earn the Muscular Dystrophy Association's Directors' Award. Dr. Rowland, who chaired the neurology department at Columbia University 1973–1998 and continues to teach there, was honored for his research in muscle and nerve physiology, and several neuromuscular conditions. Dr. R. Rodney Howell of the MDA called Dr. Rowland “the gold standard for outstanding patient care, exceptional research, and tireless leadership in the field of neuromuscular disease.”

Osteoarthritis Costs Are High

Osteoarthritis accounts for more than $185 billion in direct health care expenses each year, according to an analysis of federally collected data from 1996 to 2005. The bulk of that cost is picked up by insurance companies. However, patients face significant out-of-pocket charges. For instance, the researchers estimated that women with osteoarthritis pay $2,453 a year in out-of-pocket health care expenses, while those without the condition pay just $1,074. Among men, those with osteoarthritis have annual health expenses of $1,738, compared with $1,044 for men without the condition. The researchers analyzed data on more than 150,000 people with health insurance from the Medical Expenditure Panel Survey. The study was published in the December 2009 issue of Arthritis & Rheumatism (Arthritis. Rheum. 2009; 60:3546-53).

So Is the Bill for Knee Surgery

Spending for knee arthroplasty in the United States rose 27.5% between 2004 and 2007, to $9.2 billion, making it one of the 10 procedures most rapidly increasing in cost during that time, according to the Agency for Healthcare Research and Quality. The researchers found that hospital stays drove the upsurge. During the 4 years, the number of stays increased 25.7% to more than 600,000. The AHRQ report is available online at

www.hcup-us.ahrq.gov/reports/statbriefs/sb82.pdf

DEA Effort Delays Pain Relief

Heightened efforts by the Drug Enforcement Administration to prevent the theft of prescription narcotics are denying pain relief to many nursing home, hospice, and other long-term care patients, two senators said in a letter to Attorney General Eric Holder. Sen. Herb Kohl (D-Wis.), chairman of the Senate Special Committee on Aging, and Sen. Sheldon Whitehouse (D-R.I.) called on Holder to issue new directives to the DEA. The senators also proposed legislation that they said could fix the problem. To deter theft and diversion of prescription drugs, the agency recently stepped up enforcement of laws that require pharmacies to obtain hard copies of prescriptions with signatures from physicians, instead of routine medication orders, for controlled substances prescribed in residential-care settings. This has disrupted “well-established medication coordination protocols” and led to delays in providing those medications to sick patients, the two lawmakers said.

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Drug Promotion Levels Off

After double-digit growth earlier in the decade, promotional spending for pharmaceuticals leveled off in 2008, according to a new study by the Congressional Budget Office. That year, drug makers spent $20 billion (or about 11% of total U.S. sales) on promotional activities. The companies spent $12 billion on detailing physicians and other health care providers, $3.4 billion on sponsoring professional meetings, and $400 million on journal ads. The remainder of the spending was on direct-to-consumer ads. Much of the consumer spending was for television ads (at $1.6 billion), whereas print ads cost the industry $900 million. Manufacturers spent only $93 million in 2008 to advertise online, to sponsor links in search engines, and to host product- or disease-specific Web sites. Just 10 drugs accounted for 30% of all direct-to-consumer spending. Looking at classes of drugs, the CBO found that most consumer-directed spending promoted—in order—erectile dysfunction drugs, bone resorption inhibitors, nonbarbiturate sleep aids, autoimmune treatments, statins, serotonin norepinephrine reuptake inhibitor antidepressants, antiplatelet agents, drugs for seizure disorders, atypical antipsychotics, and central nervous system stimulants. The agency also found these drug classes to be the ones on which manufacturers spent the most money for promotion to physicians.

Firm Discloses Payments to Doctors

The drug giant GlaxoSmithKline paid $14.6 million to U.S. physicians between April 1 and June 30, 2009, according to a list of payments published by the company. The list includes the names of about 3,700 U.S. physicians and other health care professionals who received speaking or consulting fees. The average payment was $3,909, according to the company. The disclosure is part of a growing industry effort to increase transparency. GlaxoSmithKline also said it will begin publishing payments made to researchers starting in 2011.

Osteoarthritis Costs Are High

Osteoarthritis accounts for more than $185 billion in direct health care expenses each year, according to an analysis of federally collected data from 1996 to 2005. The bulk of that cost is picked up by insurance companies. However, patients face significant out-of-pocket charges. For instance, the researchers estimated that women with osteoarthritis pay $2,453 a year in out-of-pocket health care expenses, while those without the condition pay just $1,074. Among men, those with osteoarthritis have annual health expenses of $1,738, compared with $1,044 for men without the condition. The researchers analyzed data on more than 150,000 people with health insurance from the Medical Expenditure Panel Survey. The study was published in the December 2009 issue of Arthritis & Rheumatism (Arthritis. Rheum. 2009; 60:3546-53).

So Is the Bill for Knee Surgery

Spending for knee arthroplasty in the United States rose 27.5% between 2004 and 2007, to $9.2 billion, making it one of the 10 procedures most rapidly increasing in cost during that time, according to the Agency for Healthcare Research and Quality. The researchers found that hospital stays drove the upsurge. During the 4 years, the number of stays increased 25.7% to more than 600,000. The AHRQ report is available online at

www.hcup-us.ahrq.gov/reports/statbriefs/sb82.pdf

DEA Effort Delays Pain Relief

Heightened efforts by the Drug Enforcement Administration to prevent the theft of prescription narcotics are denying pain relief to many nursing home, hospice, and other long-term care patients, two senators said in a letter to Attorney General Eric Holder. Sen. Herb Kohl (D-Wis.), chairman of the Senate Special Committee on Aging, and Sen. Sheldon Whitehouse (D-R.I.) called on Holder to issue new directives to the DEA. The senators also proposed legislation that they said could fix the problem. To deter theft and diversion of prescription drugs, the agency recently stepped up enforcement of laws that require pharmacies to obtain hard copies of prescriptions with signatures from physicians, instead of routine medication orders, for controlled substances prescribed in residential-care settings. This has disrupted “well-established medication coordination protocols” and led to delays in providing those medications to sick patients, the two lawmakers said.

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Drug Promotion Levels Off

After double-digit growth earlier in the decade, promotional spending for pharmaceuticals leveled off in 2008, according to a new study by the Congressional Budget Office. That year, drug makers spent $20 billion (or about 11% of total U.S. sales) on promotional activities. The companies spent $12 billion on detailing physicians and other health care providers, $3.4 billion on sponsoring professional meetings, and $400 million on journal ads. The remainder of the spending was on direct-to-consumer ads. Much of the consumer spending was for television ads (at $1.6 billion), whereas print ads cost the industry $900 million. Manufacturers spent only $93 million in 2008 to advertise online, to sponsor links in search engines, and to host product- or disease-specific Web sites. Just 10 drugs accounted for 30% of all direct-to-consumer spending. Looking at classes of drugs, the CBO found that most consumer-directed spending promoted—in order—erectile dysfunction drugs, bone resorption inhibitors, nonbarbiturate sleep aids, autoimmune treatments, statins, serotonin norepinephrine reuptake inhibitor antidepressants, antiplatelet agents, drugs for seizure disorders, atypical antipsychotics, and central nervous system stimulants. The agency also found these drug classes to be the ones on which manufacturers spent the most money for promotion to physicians.

Firm Discloses Payments to Doctors

The drug giant GlaxoSmithKline paid $14.6 million to U.S. physicians between April 1 and June 30, 2009, according to a list of payments published by the company. The list includes the names of about 3,700 U.S. physicians and other health care professionals who received speaking or consulting fees. The average payment was $3,909, according to the company. The disclosure is part of a growing industry effort to increase transparency. GlaxoSmithKline also said it will begin publishing payments made to researchers starting in 2011.

Osteoarthritis Costs Are High

Osteoarthritis accounts for more than $185 billion in direct health care expenses each year, according to an analysis of federally collected data from 1996 to 2005. The bulk of that cost is picked up by insurance companies. However, patients face significant out-of-pocket charges. For instance, the researchers estimated that women with osteoarthritis pay $2,453 a year in out-of-pocket health care expenses, while those without the condition pay just $1,074. Among men, those with osteoarthritis have annual health expenses of $1,738, compared with $1,044 for men without the condition. The researchers analyzed data on more than 150,000 people with health insurance from the Medical Expenditure Panel Survey. The study was published in the December 2009 issue of Arthritis & Rheumatism (Arthritis. Rheum. 2009; 60:3546-53).

So Is the Bill for Knee Surgery

Spending for knee arthroplasty in the United States rose 27.5% between 2004 and 2007, to $9.2 billion, making it one of the 10 procedures most rapidly increasing in cost during that time, according to the Agency for Healthcare Research and Quality. The researchers found that hospital stays drove the upsurge. During the 4 years, the number of stays increased 25.7% to more than 600,000. The AHRQ report is available online at

www.hcup-us.ahrq.gov/reports/statbriefs/sb82.pdf

DEA Effort Delays Pain Relief

Heightened efforts by the Drug Enforcement Administration to prevent the theft of prescription narcotics are denying pain relief to many nursing home, hospice, and other long-term care patients, two senators said in a letter to Attorney General Eric Holder. Sen. Herb Kohl (D-Wis.), chairman of the Senate Special Committee on Aging, and Sen. Sheldon Whitehouse (D-R.I.) called on Holder to issue new directives to the DEA. The senators also proposed legislation that they said could fix the problem. To deter theft and diversion of prescription drugs, the agency recently stepped up enforcement of laws that require pharmacies to obtain hard copies of prescriptions with signatures from physicians, instead of routine medication orders, for controlled substances prescribed in residential-care settings. This has disrupted “well-established medication coordination protocols” and led to delays in providing those medications to sick patients, the two lawmakers said.

NIH Approves New Stem Cell Lines

Officials at the National Institutes of Health have approved 13 additional human embryonic stem cell lines eligible for federal funding, the first since the Obama administration liberalized the government's stem cell policy last July. Children's Hospital Boston developed 11 of the approved stem cell lines. The other two are from Rockefeller University, New York. Approved lines are listed on the NIH Human Embryonic Stem Cell Registry and may be used in NIH-funded research. Under the new policy, researchers can use stem cells derived from embryos that were created through in-vitro fertilization for reproductive purposes and then donated for research. More lines are under review, and NIH is expected to continue to expand its list. The human stem cell research guidelines are available online at

http://stemcells.nih.gov/policy/2009guidelines.htm

Drug Promotion Levels Off

After double-digit growth earlier in the decade, promotional spending for pharmaceuticals leveled off in 2008, according to a new study by the Congressional Budget Office. That year, drug makers spent $20 billion (or about 11% of total U.S. sales) on promotional activities. The companies spent $12 billion on detailing physicians and other health care providers, $3.4 billion on sponsoring professional meetings, and $400 million on journal ads. The remainder of the spending was on direct-to-consumer ads. Much of the consumer spending was for television ads (at $1.6 billion), whereas print ads cost the industry $900 million. Manufacturers spent only $93 million in 2008 to advertise online, to sponsor links in search engines, and to host product- or disease-specific Web sites. Just 10 drugs accounted for 30% of all direct-to-consumer spending. Looking at classes of drugs, the CBO found that most consumer-directed spending promoted—in order—erectile dysfunction drugs, bone resorption inhibitors, nonbarbiturate sleep aids, autoimmune treatments, statins, serotonin norepinephrine reuptake inhibitor antidepressants, antiplatelet agents, drugs for seizure disorders, atypical antipsychotics, and central nervous system stimulants. The agency also found these drug classes to be the ones on which manufacturers spent the most money for promotion to physicians.

Firm Discloses Payments to Doctors

The drug giant GlaxoSmithKline paid $14.6 million to U.S. physicians between April 1 and June 30, 2009, according to a list of payments published by the company. The list includes the names of about 3,700 U.S. physicians and other health care professionals who received speaking or consulting fees. The average payment was $3,909, according to the company. The disclosure is part of a growing industry effort to increase transparency. GlaxoSmithKline also said it will begin publishing payments made to researchers starting in 2011.

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Making online consults available can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

Disclosures: Dr. Bachman had no relevant disclosures.

Back pain was one of the most frequent conditions for which patients sought online consultation.

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Making online consults available can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

Disclosures: Dr. Bachman had no relevant disclosures.

Back pain was one of the most frequent conditions for which patients sought online consultation.

Source DR. BACHMAN

BOSTON — Experts have been touting the potential of virtual office visits for years, but the concept may finally be hitting the mainstream now that technology, reimbursement, and patient demand are starting to catch up.

Patients are willing to pay a reasonable fee to get advice from their physician without coming in to the office, and some will even transfer to a new practice to get this service, said Dr. John W. Bachman, a consultant in family medicine at the Mayo Clinic in Rochester, Minn. The option to go online for a medical consult is especially appealing for poorer patients who can't afford to take time off from work to get to the doctor's office, Dr. Bachman said at the annual meeting of the American Academy of Family Physicians.

“The biggest problem with doctors is that we think our patients want to be there,” Dr. Bachman said. “The fact is your patients will pay $35 not to see you.”

That's been the experience at the Mayo Clinic in Rochester, where they have been offering online consultations to established primary care patients for $35. The pilot project, which began in July 2007, uses an online patient portal to link patients and physicians. Through the portal, which was developed by Medfusion Inc., patients choose a physician and enter information about their complaint through a structured online questionnaire. They can also include a note to the provider and upload photos. “The patient has the skills to do this,” Dr. Bachman said.

Physicians receive an e-mail notification when a consult request is made. The portal allows them to bring up templates for common conditions, such as advice on sinusitis or the H1N1 virus. The portal also includes patient education materials. Physicians can also send links and attachments to the patient.

In the first 2 years of the pilot, more than 4,200 patients registered on the site. Mayo physicians provided approximately 2,531 online visits, and billings were made for 1,159 of these. Although the registration figure is low, the number of online visits and billings are the highest reported in the literature, according to Dr. Bachman.

More than 70% of the patients who participated in online visits were women, including some who were seeking consults on behalf of their children. Of the 293 conditions that were addressed during the online visits, the most frequent condition was sinusitis, with depression and back pain also coming in at the top of the list. Making online consults available can help keep the worried well out of the office, leaving time for those patients who need to come in, Dr. Bachman said.

The preliminary analysis of the first 2 years of the Mayo pilot found that online consults saved a trip to the office for about 40% of patients and saved a phone call to the office for 46% of patients. The rest of the time, patients were asked to come in to the office.

As physicians begin to do online visits using patient portals, Dr. Bachman suggested that they ask patients to pay up-front with a credit card. This makes payment immediate and establishes the identity of the patient, he said.

Disclosures: Dr. Bachman had no relevant disclosures.

Back pain was one of the most frequent conditions for which patients sought online consultation.

Source DR. BACHMAN

Over the past few years, there has been a sea change in how state governments and some physicians think about marijuana as a medicine.

Most recently, the American Medical Association's House of Delegates approved a policy recommending that the federal government review its classification of marijuana. Its current designation, as a Schedule I controlled substance, limits the ability of researchers to evaluate the drug's usefulness as a medical therapy, the AMA said. The new AMA policy states that the goal of the reclassification should be to ease the conduct of clinical research and the development of cannabinoid-based medicines and alternative delivery models.

But the policy also clearly states that the request for a federal review should not be seen as an endorsement of state-based medical cannabis programs or the legalization of marijuana.

The AMA joins other medical and public health organizations in favoring a reclassification of marijuana to encourage research. But the AMA's size and clout means people are taking notice of this recommendation, said Bruce Mirken, a spokesperson for the Marijuana Policy Project, an organization that advocates for the decriminalization of marijuana use.

“This shift is very significant, even though it was done with what you could safely call characteristic caution,” Mr. Mirken said.

Although the AMA's position won't by itself cause a swift and dramatic political shift, Mr. Mirken said the AMA's previous opposition to a change in Schedule I classification was often seized on by opponents. “They can't really say that anymore,” he said. “That, in the big picture, is significant and it may make it easier for more laws to be passed on the state level.”

Since 1996, laws that allow for some type of medical use of marijuana have been enacted in 13 states: Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington. Additional states have enacted “symbolic” laws that recognize the value of medical marijuana but do not protect individuals from arrest, according to the Marijuana Policy Project, and more states are considering medical marijuana laws.

Another development that could open the door for more states to pass medical marijuana exceptions is a recent memorandum from the Department of Justice essentially advocating a hands-off policy on medical marijuana use in states where it is allowed. In the memorandum, issued in October, the DOJ told federal prosecutors in states with laws authorizing the medical use of marijuana not to focus their resources on enforcing the federal prohibition on marijuana. For example, the prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” according to the document.

In California, where medical marijuana has been legal for more than a decade, some physicians feel they are in a precarious position. The California law states that physicians will not be punished for recommending marijuana to a patient for medical purposes. But even with the latest DOJ memo, federal enforcement is not uniform or predictable.

“That's a very uncomfortable position for a physician,” said Dr. Melvyn Sterling, a palliative care specialist in Orange, Calif. Dr. Sterling said he would prefer to see the federal government explicitly decriminalize the prescription of medical marijuana so that physicians could feel free to prescribe whatever medication is most beneficial to patients.

Dr. Sterling said that he feels comfortable recommending marijuana as a treatment when his patients need it, but that he recommends it very rarely. “For the most part we have in our therapeutic armamentarium wonderfully effective drugs, and we're not dependent upon cannabinoids,” he said.

In states that do allow physicians to recommend marijuana as a medical treatment, physicians should use caution, said Dr. Georges C. Benjamin, executive director of the American Public Health Association, which was an early supporter of more research into the medical use of marijuana. As with any other therapeutic option, physicians need to be thoroughly familiar with the drug, its utilization and side effects, contraindications, and drug-drug interactions.

“We ought to treat this like any other therapeutic drug,” he said.

It is harder to follow that advice in California, where the onus is on patients to follow up with their physician when using marijuana as medicine, according to Dr. Denise Greene, a psychiatrist and addiction specialist in the Los Angeles region. In California, physicians may “recommend” that patients obtain marijuana to treat a medical condition; the patient then takes that recommendation to a dispensary. At most dispensaries, that “recommendation” does not need to be renewed or updated, she said.

The system gives the patient an open-ended pass to obtain marijuana, Dr. Greene said, especially since unlike traditional prescriptions, these recommendations aren't time- or dose-limited.

“We don't treat this like anything else,” Dr. Greene said. “Physicians prescribe lots of other abusable drugs, but we pay attention to how much and how often and for what purpose they use those drugs.”

Mr. Milken works for the Marijuana Policy Project. Dr. Sterling uses medical marijuana in the palliative care of patients. Dr. Benjamin works for the APHA, which supports research into the medical use of marijuana.

Over the past few years, there has been a sea change in how state governments and some physicians think about marijuana as a medicine.

Most recently, the American Medical Association's House of Delegates approved a policy recommending that the federal government review its classification of marijuana. Its current designation, as a Schedule I controlled substance, limits the ability of researchers to evaluate the drug's usefulness as a medical therapy, the AMA said. The new AMA policy states that the goal of the reclassification should be to ease the conduct of clinical research and the development of cannabinoid-based medicines and alternative delivery models.

But the policy also clearly states that the request for a federal review should not be seen as an endorsement of state-based medical cannabis programs or the legalization of marijuana.

The AMA joins other medical and public health organizations in favoring a reclassification of marijuana to encourage research. But the AMA's size and clout means people are taking notice of this recommendation, said Bruce Mirken, a spokesperson for the Marijuana Policy Project, an organization that advocates for the decriminalization of marijuana use.

“This shift is very significant, even though it was done with what you could safely call characteristic caution,” Mr. Mirken said.

Although the AMA's position won't by itself cause a swift and dramatic political shift, Mr. Mirken said the AMA's previous opposition to a change in Schedule I classification was often seized on by opponents. “They can't really say that anymore,” he said. “That, in the big picture, is significant and it may make it easier for more laws to be passed on the state level.”

Since 1996, laws that allow for some type of medical use of marijuana have been enacted in 13 states: Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington. Additional states have enacted “symbolic” laws that recognize the value of medical marijuana but do not protect individuals from arrest, according to the Marijuana Policy Project, and more states are considering medical marijuana laws.

Another development that could open the door for more states to pass medical marijuana exceptions is a recent memorandum from the Department of Justice essentially advocating a hands-off policy on medical marijuana use in states where it is allowed. In the memorandum, issued in October, the DOJ told federal prosecutors in states with laws authorizing the medical use of marijuana not to focus their resources on enforcing the federal prohibition on marijuana. For example, the prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” according to the document.

In California, where medical marijuana has been legal for more than a decade, some physicians feel they are in a precarious position. The California law states that physicians will not be punished for recommending marijuana to a patient for medical purposes. But even with the latest DOJ memo, federal enforcement is not uniform or predictable.

“That's a very uncomfortable position for a physician,” said Dr. Melvyn Sterling, a palliative care specialist in Orange, Calif. Dr. Sterling said he would prefer to see the federal government explicitly decriminalize the prescription of medical marijuana so that physicians could feel free to prescribe whatever medication is most beneficial to patients.

Dr. Sterling said that he feels comfortable recommending marijuana as a treatment when his patients need it, but that he recommends it very rarely. “For the most part we have in our therapeutic armamentarium wonderfully effective drugs, and we're not dependent upon cannabinoids,” he said.

In states that do allow physicians to recommend marijuana as a medical treatment, physicians should use caution, said Dr. Georges C. Benjamin, executive director of the American Public Health Association, which was an early supporter of more research into the medical use of marijuana. As with any other therapeutic option, physicians need to be thoroughly familiar with the drug, its utilization and side effects, contraindications, and drug-drug interactions.

“We ought to treat this like any other therapeutic drug,” he said.

It is harder to follow that advice in California, where the onus is on patients to follow up with their physician when using marijuana as medicine, according to Dr. Denise Greene, a psychiatrist and addiction specialist in the Los Angeles region. In California, physicians may “recommend” that patients obtain marijuana to treat a medical condition; the patient then takes that recommendation to a dispensary. At most dispensaries, that “recommendation” does not need to be renewed or updated, she said.

The system gives the patient an open-ended pass to obtain marijuana, Dr. Greene said, especially since unlike traditional prescriptions, these recommendations aren't time- or dose-limited.

“We don't treat this like anything else,” Dr. Greene said. “Physicians prescribe lots of other abusable drugs, but we pay attention to how much and how often and for what purpose they use those drugs.”

Mr. Milken works for the Marijuana Policy Project. Dr. Sterling uses medical marijuana in the palliative care of patients. Dr. Benjamin works for the APHA, which supports research into the medical use of marijuana.

Over the past few years, there has been a sea change in how state governments and some physicians think about marijuana as a medicine.

Most recently, the American Medical Association's House of Delegates approved a policy recommending that the federal government review its classification of marijuana. Its current designation, as a Schedule I controlled substance, limits the ability of researchers to evaluate the drug's usefulness as a medical therapy, the AMA said. The new AMA policy states that the goal of the reclassification should be to ease the conduct of clinical research and the development of cannabinoid-based medicines and alternative delivery models.

But the policy also clearly states that the request for a federal review should not be seen as an endorsement of state-based medical cannabis programs or the legalization of marijuana.

The AMA joins other medical and public health organizations in favoring a reclassification of marijuana to encourage research. But the AMA's size and clout means people are taking notice of this recommendation, said Bruce Mirken, a spokesperson for the Marijuana Policy Project, an organization that advocates for the decriminalization of marijuana use.

“This shift is very significant, even though it was done with what you could safely call characteristic caution,” Mr. Mirken said.

Although the AMA's position won't by itself cause a swift and dramatic political shift, Mr. Mirken said the AMA's previous opposition to a change in Schedule I classification was often seized on by opponents. “They can't really say that anymore,” he said. “That, in the big picture, is significant and it may make it easier for more laws to be passed on the state level.”

Since 1996, laws that allow for some type of medical use of marijuana have been enacted in 13 states: Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington. Additional states have enacted “symbolic” laws that recognize the value of medical marijuana but do not protect individuals from arrest, according to the Marijuana Policy Project, and more states are considering medical marijuana laws.

Another development that could open the door for more states to pass medical marijuana exceptions is a recent memorandum from the Department of Justice essentially advocating a hands-off policy on medical marijuana use in states where it is allowed. In the memorandum, issued in October, the DOJ told federal prosecutors in states with laws authorizing the medical use of marijuana not to focus their resources on enforcing the federal prohibition on marijuana. For example, the prosecution of cancer patients who use marijuana as part of a recommended treatment regimen is “unlikely to be an efficient use of limited federal resources,” according to the document.

In California, where medical marijuana has been legal for more than a decade, some physicians feel they are in a precarious position. The California law states that physicians will not be punished for recommending marijuana to a patient for medical purposes. But even with the latest DOJ memo, federal enforcement is not uniform or predictable.

“That's a very uncomfortable position for a physician,” said Dr. Melvyn Sterling, a palliative care specialist in Orange, Calif. Dr. Sterling said he would prefer to see the federal government explicitly decriminalize the prescription of medical marijuana so that physicians could feel free to prescribe whatever medication is most beneficial to patients.

Dr. Sterling said that he feels comfortable recommending marijuana as a treatment when his patients need it, but that he recommends it very rarely. “For the most part we have in our therapeutic armamentarium wonderfully effective drugs, and we're not dependent upon cannabinoids,” he said.

In states that do allow physicians to recommend marijuana as a medical treatment, physicians should use caution, said Dr. Georges C. Benjamin, executive director of the American Public Health Association, which was an early supporter of more research into the medical use of marijuana. As with any other therapeutic option, physicians need to be thoroughly familiar with the drug, its utilization and side effects, contraindications, and drug-drug interactions.

“We ought to treat this like any other therapeutic drug,” he said.

It is harder to follow that advice in California, where the onus is on patients to follow up with their physician when using marijuana as medicine, according to Dr. Denise Greene, a psychiatrist and addiction specialist in the Los Angeles region. In California, physicians may “recommend” that patients obtain marijuana to treat a medical condition; the patient then takes that recommendation to a dispensary. At most dispensaries, that “recommendation” does not need to be renewed or updated, she said.

The system gives the patient an open-ended pass to obtain marijuana, Dr. Greene said, especially since unlike traditional prescriptions, these recommendations aren't time- or dose-limited.

“We don't treat this like anything else,” Dr. Greene said. “Physicians prescribe lots of other abusable drugs, but we pay attention to how much and how often and for what purpose they use those drugs.”

Mr. Milken works for the Marijuana Policy Project. Dr. Sterling uses medical marijuana in the palliative care of patients. Dr. Benjamin works for the APHA, which supports research into the medical use of marijuana.