Mary Ellen Schneider

SAN DIEGO — Preparing a budget and regularly compiling financial reports is critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

“It's important to keep your eye on your cash flow,” said Margo J. Williams of the ACP Practice Management Center in Washington.

Several standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the ACP Practice Management Center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said.

“An awful lot of practices never bother to prepare a budget,” he said. “I would strongly encourage you to do so because what it does is provide a planned income statement.”

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, Mr. Cunningham said.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc

SAN DIEGO — Preparing a budget and regularly compiling financial reports is critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

“It's important to keep your eye on your cash flow,” said Margo J. Williams of the ACP Practice Management Center in Washington.

Several standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the ACP Practice Management Center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said.

“An awful lot of practices never bother to prepare a budget,” he said. “I would strongly encourage you to do so because what it does is provide a planned income statement.”

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, Mr. Cunningham said.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc

SAN DIEGO — Preparing a budget and regularly compiling financial reports is critical for any physician practice to maintain a healthy bottom line, financial experts said at the annual meeting of the American College of Physicians.

“It's important to keep your eye on your cash flow,” said Margo J. Williams of the ACP Practice Management Center in Washington.

Several standard financial monitoring tools—balance sheets, income statements, budgets, and accounts receivable reports—can help give physicians an overall picture of how the practice is doing and provide early warning of potential problems.

The balance sheet is often misunderstood, said Carl B. Cunningham, director of the ACP Practice Management Center. For the average physician practice, the balance sheet is mainly useful when trying to sell the practice because it lists the accumulated assets and liabilities. However, because the balance sheet is really just a snapshot of one point in time, it's not very useful in managing the practice day to day, he said.

A better tool for daily management of the practice is the income statement, Mr. Cunningham said. This allows physicians to measure, over a specific period, their revenues and expenses. He recommends analyzing the income statement monthly.

But the income statement also has a drawback: It describes the financial state of the practice, but it doesn't help determine how the practice should be performing. That's where having a budget comes in, Mr. Cunningham said.

“An awful lot of practices never bother to prepare a budget,” he said. “I would strongly encourage you to do so because what it does is provide a planned income statement.”

By preparing a budget, physicians can sit down in advance and figure out where they want to be financially and what types of expenses and revenue will be needed to get there. This type of budgeting exercise can be done for the whole practice, as well as when evaluating new ancillary services. And because the budget is there to serve as the guideline, it can also help physicians delegate some financial tasks to other staff, Mr. Cunningham said.

For those physicians who are ACP members, the staff at the Practice Management Center can provide a one-page summary of the practice's key financial data. The one-page report includes charges, patient visits, and accounts receivable by month and year-to-date. This tool can be an easy way for a busy physician to quickly evaluate his or her practice, Mr. Cunningham said.

“Accounts receivable management is another area that is critical to monitoring the financial status of your practice,” Ms. Williams said.

Accounts receivable, which is the money that is due but has not yet been received, is an area where everyone from the front desk receptionist to the physician can play a role, she said. The goal should be to get things right the first time in terms of getting out clean claims, staying on top of denials, and finding out why claims are being denied.

Continuous monitoring of accounts receivable also is important. Some of the tools that physicians and their staff can use to oversee this area include tracking the days in accounts receivable, to find out how long it takes to collect, and calculating gross and net collection ratios, which show how much is being collected.

The average number of days that charges spend in accounts receivable can be calculated in two steps. First, take the total charges and divide by 365 days to get the average daily charges. Then, take the total accounts receivable balance and divide by the average daily charges. For most practices, the average number of days in accounts receivable is about 37, Ms. Williams said.

Collection ratios can be helpful in determining the share of the accounts receivable that has actually been collected. But when calculating collection ratios, keep in mind that the gross collection ratio is easy to figure out but is influenced by the fee discount contracted with payers, and so it is not a pure measure of collections performance.

The net collection ratio is a better indicator of performance because it is based on contracted fees that can actually be collected. However, this number is difficult to calculate without a sophisticated practice management system that builds accurate payer fee schedules into the computer, Ms. Williams said.

Information on the ACP Practice Management Center is available online at www.acponline.org/pmc

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again.

When you are faced with prior authorization, save time by having the patient collect the authorization forms and bring them into the office, Dr. Mitchell suggested. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

During the course of Part D implementation, Dr. Mitchell also learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again.

When you are faced with prior authorization, save time by having the patient collect the authorization forms and bring them into the office, Dr. Mitchell suggested. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

During the course of Part D implementation, Dr. Mitchell also learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

SAN DIEGO — In the second year of Medicare Part D implementation, physicians continue to struggle with prior authorization requests and other hassles, Dr. Kay M. Mitchell said at the annual meeting of the American College of Physicians.

Although some of the paperwork burden remains, the prescription drug program is generally easier to manage now because patients and physicians are more familiar with the rules, said Dr. Mitchell, a geriatrician and a professor in the department of community internal medicine at the Mayo Clinic in Jacksonville, Fla.

“It's still going to cost us time and money,” Dr. Mitchell said. “It doesn't matter how much we've worked at it.”

For example, physicians continue to see requests for prior authorization and step therapy, said Neil M. Kirschner, Ph.D., ACP's senior associate of insurer and regulatory affairs. In addition, in 2007, several drugs were approved under both Medicare Part B and Part D, which could create denials, he said.

Officials at the Centers for Medicare and Medicaid Services are working on this issue and recommend that physicians write the diagnosis and “Part D” on the prescription, Dr. Kirschner said.

Physicians might experience some relief in terms of prior authorization and exceptions if their patients haven't changed drug plans, Dr. Mitchell said. CMS officials announced that prior authorizations and exceptions approved by a drug plan in 2006 are expected to continue this year if the beneficiary remains in the same plan and the expiration date hasn't occurred by Dec. 31, 2006. However, if the beneficiary changes plans, physicians might have to go through the same process again.

When you are faced with prior authorization, save time by having the patient collect the authorization forms and bring them into the office, Dr. Mitchell suggested. In her office, this saves office staff 20–35 minutes per prescription, she said.

Some physicians have decided to deal with the extra Part D paperwork by either hiring additional staff or designating staff to deal solely with Part D prior authorizations, denials, and appeals, Dr. Mitchell said. Some physicians use general office staff while others use nursing staff. Dr. Mitchell said she prefers to have one of her nurses work on Part D issues because she is already familiar with the patients and their medications.

Dr. Mitchell also recommended that staff members who are working on Part D issues attend continuing medical education meetings that focus on Part D.

During the course of Part D implementation, Dr. Mitchell also learned that insurers may ask for documentation justifying a switch in medications. To simplify that process, she recommends, keep a sheet in the front of the chart with information on medication changes and the reasons for the switch.

NEW YORK — Distinguishing between type 1 and type 2 diabetes can be difficult given the increase in the number of overweight and obese children, Dr. Larry C. Deeb said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

“It is not crystal clear,” he said.

The rising number of overweight and obese children in the United States means that more and more children are getting type 2 diabetes, but more children with type 1 diabetes also are overweight.

The classic picture of a child who is wasting away is frequently not the case in type 1 diabetes anymore. In fact, up to a quarter of children with type 1 diabetes might be overweight, said Dr. Deeb, president of medicine and science for the American Diabetes Association and medical director of the Diabetes Center at Tallahassee Memorial Hospital in Florida.

However, there are differences in presentation of illness that can help physicians distinguish between the two conditions.

Type 1 diabetes in children continues to be characterized by a short course of illness, Dr. Deeb said. About 35%–40% of subjects will have ketoacidosis. In children with type 1 diabetes, the C-peptide and insulin levels will decrease, but they might be preserved early on.

In some cases, family history can be a clue. About 5% of subjects have first- or second-degree relatives with type 1 diabetes.

Race and ethnicity also can help physicians figure out whether the diabetes is type 1 or type 2. Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States, he said.

When dealing with type 2 diabetes, overweight is a significant factor. About 85% of subjects with type 2 diabetes will be overweight.

In general, the course of type 2 diabetes in children will be indolent. But a significant proportion, about 33% of subjects, will have ketonuria. And a surprising number, 5%–25%, have mild ketoacidosis, Dr. Deeb said.

Many children and adolescents at highest risk for type 2 diabetes are not being seen by a physician, Dr. Deeb said. “You have some parents who bring children in, but the vast majority is not seen,” he said. “This teen group is at risk to develop diabetes, and by the time they're at risk, they're not being seen. Therefore, they very well be may be all the way to sick.”

In children with type 2 diabetes, C-peptide and insulin levels might increase, but they can be low at diagnosis with glucotoxicity and lipotoxicity.

Type 2 diabetes also is associated with insulin resistance, hypertension, dyslipidemia, polycystic ovary syndrome (PCOS), and acanthosis nigricans. “I never dreamed that I would treat so much PCOS as a pediatric endocrinologist,” Dr. Deeb said.

Family history can be a strong indicator of type 2 diabetes. Between 74% and 100% of these children will have a first- or second-degree relative with type 2 diabetes. In terms of race and ethnicity, type 2 diabetes is predominantly a disease of minority youth, but white children still have it, he said.

Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States. DR. DEEB

NEW YORK — Distinguishing between type 1 and type 2 diabetes can be difficult given the increase in the number of overweight and obese children, Dr. Larry C. Deeb said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

“It is not crystal clear,” he said.

The rising number of overweight and obese children in the United States means that more and more children are getting type 2 diabetes, but more children with type 1 diabetes also are overweight.

The classic picture of a child who is wasting away is frequently not the case in type 1 diabetes anymore. In fact, up to a quarter of children with type 1 diabetes might be overweight, said Dr. Deeb, president of medicine and science for the American Diabetes Association and medical director of the Diabetes Center at Tallahassee Memorial Hospital in Florida.

However, there are differences in presentation of illness that can help physicians distinguish between the two conditions.

Type 1 diabetes in children continues to be characterized by a short course of illness, Dr. Deeb said. About 35%–40% of subjects will have ketoacidosis. In children with type 1 diabetes, the C-peptide and insulin levels will decrease, but they might be preserved early on.

In some cases, family history can be a clue. About 5% of subjects have first- or second-degree relatives with type 1 diabetes.

Race and ethnicity also can help physicians figure out whether the diabetes is type 1 or type 2. Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States, he said.

When dealing with type 2 diabetes, overweight is a significant factor. About 85% of subjects with type 2 diabetes will be overweight.

In general, the course of type 2 diabetes in children will be indolent. But a significant proportion, about 33% of subjects, will have ketonuria. And a surprising number, 5%–25%, have mild ketoacidosis, Dr. Deeb said.

Many children and adolescents at highest risk for type 2 diabetes are not being seen by a physician, Dr. Deeb said. “You have some parents who bring children in, but the vast majority is not seen,” he said. “This teen group is at risk to develop diabetes, and by the time they're at risk, they're not being seen. Therefore, they very well be may be all the way to sick.”

In children with type 2 diabetes, C-peptide and insulin levels might increase, but they can be low at diagnosis with glucotoxicity and lipotoxicity.

Type 2 diabetes also is associated with insulin resistance, hypertension, dyslipidemia, polycystic ovary syndrome (PCOS), and acanthosis nigricans. “I never dreamed that I would treat so much PCOS as a pediatric endocrinologist,” Dr. Deeb said.

Family history can be a strong indicator of type 2 diabetes. Between 74% and 100% of these children will have a first- or second-degree relative with type 2 diabetes. In terms of race and ethnicity, type 2 diabetes is predominantly a disease of minority youth, but white children still have it, he said.

Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States. DR. DEEB

NEW YORK — Distinguishing between type 1 and type 2 diabetes can be difficult given the increase in the number of overweight and obese children, Dr. Larry C. Deeb said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

“It is not crystal clear,” he said.

The rising number of overweight and obese children in the United States means that more and more children are getting type 2 diabetes, but more children with type 1 diabetes also are overweight.

The classic picture of a child who is wasting away is frequently not the case in type 1 diabetes anymore. In fact, up to a quarter of children with type 1 diabetes might be overweight, said Dr. Deeb, president of medicine and science for the American Diabetes Association and medical director of the Diabetes Center at Tallahassee Memorial Hospital in Florida.

However, there are differences in presentation of illness that can help physicians distinguish between the two conditions.

Type 1 diabetes in children continues to be characterized by a short course of illness, Dr. Deeb said. About 35%–40% of subjects will have ketoacidosis. In children with type 1 diabetes, the C-peptide and insulin levels will decrease, but they might be preserved early on.

In some cases, family history can be a clue. About 5% of subjects have first- or second-degree relatives with type 1 diabetes.

Race and ethnicity also can help physicians figure out whether the diabetes is type 1 or type 2. Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States, he said.

When dealing with type 2 diabetes, overweight is a significant factor. About 85% of subjects with type 2 diabetes will be overweight.

In general, the course of type 2 diabetes in children will be indolent. But a significant proportion, about 33% of subjects, will have ketonuria. And a surprising number, 5%–25%, have mild ketoacidosis, Dr. Deeb said.

Many children and adolescents at highest risk for type 2 diabetes are not being seen by a physician, Dr. Deeb said. “You have some parents who bring children in, but the vast majority is not seen,” he said. “This teen group is at risk to develop diabetes, and by the time they're at risk, they're not being seen. Therefore, they very well be may be all the way to sick.”

In children with type 2 diabetes, C-peptide and insulin levels might increase, but they can be low at diagnosis with glucotoxicity and lipotoxicity.

Type 2 diabetes also is associated with insulin resistance, hypertension, dyslipidemia, polycystic ovary syndrome (PCOS), and acanthosis nigricans. “I never dreamed that I would treat so much PCOS as a pediatric endocrinologist,” Dr. Deeb said.

Family history can be a strong indicator of type 2 diabetes. Between 74% and 100% of these children will have a first- or second-degree relative with type 2 diabetes. In terms of race and ethnicity, type 2 diabetes is predominantly a disease of minority youth, but white children still have it, he said.

Type 1 diabetes is still a disease mostly of whites and northern Europeans in the United States. DR. DEEB

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, according to Dr. Langer.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, according to Dr. Langer.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26 to 28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan into place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, according to Dr. Langer.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although the results of the Diabetes Prevention Program and most other current studies show that lifestyle interventions produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, who serves as director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are generally becoming less conservative in their recommendations about exercise for pregnant women. For example, Dr. Pivarnik said, the American College of Obstetricians and Gynecologists has revised its recommendations on exercise in pregnancy three times in the last 2 decades, and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just didn't follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity among recreational and competitive athletes. Specifically, the guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. However, since information on strenuous exercise is limited, these women require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, according to the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines recommend that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done,” he said.

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, who serves as director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are generally becoming less conservative in their recommendations about exercise for pregnant women. For example, Dr. Pivarnik said, the American College of Obstetricians and Gynecologists has revised its recommendations on exercise in pregnancy three times in the last 2 decades, and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just didn't follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity among recreational and competitive athletes. Specifically, the guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. However, since information on strenuous exercise is limited, these women require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, according to the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines recommend that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done,” he said.

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

NEW YORK — What physicians and researchers know for sure about physical activity during pregnancy hasn't changed much since the early 1900s, James M. Pivarnik, Ph.D., said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Recommendations from the Handbook for Prospective Mothers, published in 1913, advised pregnant women that the amount of exercise needed cannot be precisely stated, walking is the best kind of exercise, and all kinds of violent exertion should be avoided. While today's recommendations have been more thoroughly researched, they don't provide women with many more definitive answers, said Dr. Pivarnik, who serves as director of the Center for Physical Activity and Health at Michigan State University in East Lansing.

But professional medical societies are generally becoming less conservative in their recommendations about exercise for pregnant women. For example, Dr. Pivarnik said, the American College of Obstetricians and Gynecologists has revised its recommendations on exercise in pregnancy three times in the last 2 decades, and has moved away from strict limits on physical activity.

In 1985, ACOG released its first exercise guidelines for pregnant women, which included time limits for exercise and recommended that a woman's heart rate not exceed 140 beats per minute. However, even these early guidelines included the disclaimer that physically fit pregnant woman may tolerate a more strenuous program.

“There was actually the dispensation way back then but a lot of people just didn't follow that,” Dr. Pivarnik said.

In 1994, ACOG issued updated guidelines that were less cautious and emphasized the benefits of mild to moderate exercise at least 3 days a week. “There was more stress on the health benefits, rather than the fear,” he said.

The most recent ACOG guidelines on exercise in pregnancy were issued in 2002 and address activity among recreational and competitive athletes. Specifically, the guidelines recommend that athletes with uncomplicated pregnancies can remain active during pregnancy and should modify their routines as medically indicated. However, since information on strenuous exercise is limited, these women require close medical supervision.

And most pregnant women without medical or obstetric complications can aim to engage in 30 minutes or more of moderate exercise a day, according to the guidelines.

Guidelines issued in Canada in 2003 by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology take an even more aggressive approach. The joint 2003 guidelines recommend that all women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises during pregnancy.

But some physicians and nurse-midwives who deal with obstetrics are not up to date on the guidelines and still recommend more conservative approaches, such as not exceeding a heart rate of 140 beats per minute, Dr. Pivarnik said. “There's no evidence that that's the way it should be done,” he said.

Guidelines on exercise in pregnancy are moving away from strict activity limits. Stanford W. Carpenter

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP.

“Where the action is really taking place is at the state level,” he said.

There are comprehensive plans aimed at covering the uninsured in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP). More states are considering plans for universal health coverage for children.

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal legislative proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and federal grants for state initiatives.

Most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP.

“Where the action is really taking place is at the state level,” he said.

There are comprehensive plans aimed at covering the uninsured in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP). More states are considering plans for universal health coverage for children.

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal legislative proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and federal grants for state initiatives.

Most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP.

“Where the action is really taking place is at the state level,” he said.

There are comprehensive plans aimed at covering the uninsured in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP). More states are considering plans for universal health coverage for children.

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal legislative proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and federal grants for state initiatives.

Most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

Texas Shoots Down Gardasil Mandate

Texas lawmakers recently rejected Gov. Rick Perry's (R) mandate that 11- to 12-year-old girls in the state be vaccinated against human papillomavirus (HPV) before entry into the sixth grade. The legislature overwhelmingly approved a bill that bars the state from ordering the shots for at least the next 4 years. Gov. Perry allowed the bill to become law without his signature in early May. In February, Gov. Perry signed an executive order requiring the shots, but many legislators opposed the move, saying parents should decide whether to vaccinate against a sexually transmitted disease. The Texas Medical Association (TMA) did not support the state mandate, even though “the science behind the HPV vaccine is strong and physicians are excited that this vaccine will prevent about 70% of cervical cancer cases and 90% of cases of genital warts,” TMA President Dr. William Hinchey said in a statement.

Tort Reform Vetoed in Oklahoma

Oklahoma Gov. Brad Henry (D) recently vetoed a tort reform measure that would have capped noneconomic damages in medical malpractice cases at $300,000. However, the governor left the door open to the possibility of signing a “compromise” reform package in the future. Gov. Henry vetoed S.B. 507 and cited concerns that several provisions of the bill were unconstitutional and that it did not do enough to curb frivolous lawsuits. “The key to curbing frivolous lawsuits is stopping them at the front end of the legal system, not limiting the damages or penalties awarded at the back end after a guilty verdict is handed down,” he said in a statement. The bill was supported by the Oklahoma State Medical Association.

Contraceptive Coverage Favored

More than 80% of U.S. adults say that birth control should be covered, at least in part, by health insurance, according to the results of a Harris Interactive poll. More women than men favored some level of insurance coverage for birth control medications and procedures, with 88% of women saying it should be covered, compared with 72% of men. Further, about 63% of adults favored some level of insurance coverage for in vitro fertilization, whereas 25% were against insurance coverage for the procedure, and 13% were unsure. Again, more women than men favored insurance coverage, with 69% of women surveyed saying in vitro fertilization should be covered, compared with 55% of men. A smaller percentage of individuals surveyed agreed that insurance should cover drugs to treat erectile or other sexual dysfunction. Fifty percent of U.S. adults surveyed said that they favored insurance coverage, at least in part, for drugs to treat sexual dysfunction. The results are based on an online nationwide survey of 2,402 adults.

Lawmakers Target Cigarette Sellers

Senators are asking the Federal Trade Commission to investigate R.J. Reynolds Tobacco Co. on the grounds of marketing its products to children. In a letter to the FTC, Sen. Tom Harkin (D-Iowa) and Sen. Frank Lautenberg (D-N.J.) said that R.J. Reynolds is attempting to attract young girls to its Camel No. 9 cigarettes. The product is being advertised as “light and luscious” in popular women's magazines. The senators said the advertising campaign aims to appeal to teenage girls, who make up more than 10% of the readership of women's magazines. “The persistence of advertising that entices our young people to smoke is simply unacceptable,” Sen. Harkin said in a statement. “We cannot tolerate ads that encourage our young people to do something that is illegal and that will harm their health.” The tobacco company also was criticized by the Society for Women's Health Research for the marketing of Camel No. 9, which the group said is clearly aimed at attracting a “new generation of young women smokers.” But a spokesman for R.J. Reynolds said company officials are confident that their marketing practices abide by all FTC guidelines.

Weems Named Medicare Chief

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the Centers for Medicare and Medicaid Services. Mr. Weems is now deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid and what it will take to strengthen and sustain those programs [and] has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems, which will be a valuable asset to CMS,” Mr. Leavitt said in a statement. If confirmed by the Senate, Mr. Weems will fill the vacancy left by Dr. Mark B. McClellan, who resigned from the CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

Texas Shoots Down Gardasil Mandate

Texas lawmakers recently rejected Gov. Rick Perry's (R) mandate that 11- to 12-year-old girls in the state be vaccinated against human papillomavirus (HPV) before entry into the sixth grade. The legislature overwhelmingly approved a bill that bars the state from ordering the shots for at least the next 4 years. Gov. Perry allowed the bill to become law without his signature in early May. In February, Gov. Perry signed an executive order requiring the shots, but many legislators opposed the move, saying parents should decide whether to vaccinate against a sexually transmitted disease. The Texas Medical Association (TMA) did not support the state mandate, even though “the science behind the HPV vaccine is strong and physicians are excited that this vaccine will prevent about 70% of cervical cancer cases and 90% of cases of genital warts,” TMA President Dr. William Hinchey said in a statement.

Tort Reform Vetoed in Oklahoma

Oklahoma Gov. Brad Henry (D) recently vetoed a tort reform measure that would have capped noneconomic damages in medical malpractice cases at $300,000. However, the governor left the door open to the possibility of signing a “compromise” reform package in the future. Gov. Henry vetoed S.B. 507 and cited concerns that several provisions of the bill were unconstitutional and that it did not do enough to curb frivolous lawsuits. “The key to curbing frivolous lawsuits is stopping them at the front end of the legal system, not limiting the damages or penalties awarded at the back end after a guilty verdict is handed down,” he said in a statement. The bill was supported by the Oklahoma State Medical Association.

Contraceptive Coverage Favored

More than 80% of U.S. adults say that birth control should be covered, at least in part, by health insurance, according to the results of a Harris Interactive poll. More women than men favored some level of insurance coverage for birth control medications and procedures, with 88% of women saying it should be covered, compared with 72% of men. Further, about 63% of adults favored some level of insurance coverage for in vitro fertilization, whereas 25% were against insurance coverage for the procedure, and 13% were unsure. Again, more women than men favored insurance coverage, with 69% of women surveyed saying in vitro fertilization should be covered, compared with 55% of men. A smaller percentage of individuals surveyed agreed that insurance should cover drugs to treat erectile or other sexual dysfunction. Fifty percent of U.S. adults surveyed said that they favored insurance coverage, at least in part, for drugs to treat sexual dysfunction. The results are based on an online nationwide survey of 2,402 adults.

Lawmakers Target Cigarette Sellers

Senators are asking the Federal Trade Commission to investigate R.J. Reynolds Tobacco Co. on the grounds of marketing its products to children. In a letter to the FTC, Sen. Tom Harkin (D-Iowa) and Sen. Frank Lautenberg (D-N.J.) said that R.J. Reynolds is attempting to attract young girls to its Camel No. 9 cigarettes. The product is being advertised as “light and luscious” in popular women's magazines. The senators said the advertising campaign aims to appeal to teenage girls, who make up more than 10% of the readership of women's magazines. “The persistence of advertising that entices our young people to smoke is simply unacceptable,” Sen. Harkin said in a statement. “We cannot tolerate ads that encourage our young people to do something that is illegal and that will harm their health.” The tobacco company also was criticized by the Society for Women's Health Research for the marketing of Camel No. 9, which the group said is clearly aimed at attracting a “new generation of young women smokers.” But a spokesman for R.J. Reynolds said company officials are confident that their marketing practices abide by all FTC guidelines.

Weems Named Medicare Chief

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the Centers for Medicare and Medicaid Services. Mr. Weems is now deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid and what it will take to strengthen and sustain those programs [and] has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems, which will be a valuable asset to CMS,” Mr. Leavitt said in a statement. If confirmed by the Senate, Mr. Weems will fill the vacancy left by Dr. Mark B. McClellan, who resigned from the CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

Texas Shoots Down Gardasil Mandate

Texas lawmakers recently rejected Gov. Rick Perry's (R) mandate that 11- to 12-year-old girls in the state be vaccinated against human papillomavirus (HPV) before entry into the sixth grade. The legislature overwhelmingly approved a bill that bars the state from ordering the shots for at least the next 4 years. Gov. Perry allowed the bill to become law without his signature in early May. In February, Gov. Perry signed an executive order requiring the shots, but many legislators opposed the move, saying parents should decide whether to vaccinate against a sexually transmitted disease. The Texas Medical Association (TMA) did not support the state mandate, even though “the science behind the HPV vaccine is strong and physicians are excited that this vaccine will prevent about 70% of cervical cancer cases and 90% of cases of genital warts,” TMA President Dr. William Hinchey said in a statement.

Tort Reform Vetoed in Oklahoma

Oklahoma Gov. Brad Henry (D) recently vetoed a tort reform measure that would have capped noneconomic damages in medical malpractice cases at $300,000. However, the governor left the door open to the possibility of signing a “compromise” reform package in the future. Gov. Henry vetoed S.B. 507 and cited concerns that several provisions of the bill were unconstitutional and that it did not do enough to curb frivolous lawsuits. “The key to curbing frivolous lawsuits is stopping them at the front end of the legal system, not limiting the damages or penalties awarded at the back end after a guilty verdict is handed down,” he said in a statement. The bill was supported by the Oklahoma State Medical Association.

Contraceptive Coverage Favored

More than 80% of U.S. adults say that birth control should be covered, at least in part, by health insurance, according to the results of a Harris Interactive poll. More women than men favored some level of insurance coverage for birth control medications and procedures, with 88% of women saying it should be covered, compared with 72% of men. Further, about 63% of adults favored some level of insurance coverage for in vitro fertilization, whereas 25% were against insurance coverage for the procedure, and 13% were unsure. Again, more women than men favored insurance coverage, with 69% of women surveyed saying in vitro fertilization should be covered, compared with 55% of men. A smaller percentage of individuals surveyed agreed that insurance should cover drugs to treat erectile or other sexual dysfunction. Fifty percent of U.S. adults surveyed said that they favored insurance coverage, at least in part, for drugs to treat sexual dysfunction. The results are based on an online nationwide survey of 2,402 adults.

Lawmakers Target Cigarette Sellers

Senators are asking the Federal Trade Commission to investigate R.J. Reynolds Tobacco Co. on the grounds of marketing its products to children. In a letter to the FTC, Sen. Tom Harkin (D-Iowa) and Sen. Frank Lautenberg (D-N.J.) said that R.J. Reynolds is attempting to attract young girls to its Camel No. 9 cigarettes. The product is being advertised as “light and luscious” in popular women's magazines. The senators said the advertising campaign aims to appeal to teenage girls, who make up more than 10% of the readership of women's magazines. “The persistence of advertising that entices our young people to smoke is simply unacceptable,” Sen. Harkin said in a statement. “We cannot tolerate ads that encourage our young people to do something that is illegal and that will harm their health.” The tobacco company also was criticized by the Society for Women's Health Research for the marketing of Camel No. 9, which the group said is clearly aimed at attracting a “new generation of young women smokers.” But a spokesman for R.J. Reynolds said company officials are confident that their marketing practices abide by all FTC guidelines.

Weems Named Medicare Chief

President Bush recently nominated Kerry N. Weems, a 24-year veteran of the Department of Health and Human Services, to lead the Centers for Medicare and Medicaid Services. Mr. Weems is now deputy chief of staff to HHS Secretary Mike Leavitt. “He understands the large fiscal challenges facing Medicare and Medicaid and what it will take to strengthen and sustain those programs [and] has been a leader in this department's efforts to accelerate adoption of health information technology and better financial management systems, which will be a valuable asset to CMS,” Mr. Leavitt said in a statement. If confirmed by the Senate, Mr. Weems will fill the vacancy left by Dr. Mark B. McClellan, who resigned from the CMS last year. Leslie V. Norwalk is the current acting CMS administrator.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry, most frequently receiving food in the workplace (83%); 78% also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments for consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356;1742–50).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were more than twice as likely as family physicians to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those in hospitals, clinics, or staff-model health maintenance organizations, three times as likely to receive gifts, and nearly four times as likely to receive payments for professional services.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since it is a common practice for physicians to accept drug samples in an effort to save their patients money. Most practices are likely operating within the guidelines set out by the American Medical Association, he said. The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The relationship with industry should continue to be watched and addressed, said Dr. King, who recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

Dr. Jack Lewin, CEO of the American College of Cardiology, called for an increase in the number of publicly funded independent reviews of drugs and devices. Increases in federal research funding would help to clarify some of the gray areas of cardiovascular care, he added.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry, most frequently receiving food in the workplace (83%); 78% also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments for consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356;1742–50).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were more than twice as likely as family physicians to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those in hospitals, clinics, or staff-model health maintenance organizations, three times as likely to receive gifts, and nearly four times as likely to receive payments for professional services.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since it is a common practice for physicians to accept drug samples in an effort to save their patients money. Most practices are likely operating within the guidelines set out by the American Medical Association, he said. The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The relationship with industry should continue to be watched and addressed, said Dr. King, who recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

Dr. Jack Lewin, CEO of the American College of Cardiology, called for an increase in the number of publicly funded independent reviews of drugs and devices. Increases in federal research funding would help to clarify some of the gray areas of cardiovascular care, he added.

Nearly all physicians have ties to the pharmaceutical or device industries ranging from accepting drug samples to serving on a speakers' bureau, according to a survey of physicians across six specialties.

The study found that 94% of physicians surveyed reported some type of relationship with industry, most frequently receiving food in the workplace (83%); 78% also reported accepting drug samples.

Fewer physicians, about 35%, reported accepting reimbursement for admission to continuing medical education meetings or other meeting-related expenses, and 28% said they received payments for consulting, speaking, serving on an advisory board, or enrolling patients in clinical trials (N. Engl. J. Med. 2007;356;1742–50).

Physicians contacted by this news organization said that while the study raises important issues, it is not a cause for alarm since many of the industry interactions outlined in the study are essential and appropriate.

Eric G. Campbell, Ph.D., of the Institute for Health Policy at Massachusetts General Hospital-Partners Health Care System in Boston, and his colleagues surveyed 3,167 physicians working in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics. Of those surveyed, 1,662 completed the questionnaire for an overall response rate of about 52%. The study was supported by a grant from the Institute on Medicine as a Profession.

The type and extent of reported interaction with representatives of the pharmaceutical and device industries varied by specialty, the researchers found. For example, cardiologists were more than twice as likely as family physicians to receive payments for professional services, such as consulting or work on clinical trials.

Family physicians held the most meetings with industry representatives, on average about 16 meetings per month, according to the study.

Practice setting also played a role in the interaction. Physicians in group practice were six times more likely to receive drug samples than were those in hospitals, clinics, or staff-model health maintenance organizations, three times as likely to receive gifts, and nearly four times as likely to receive payments for professional services.

In an interview, Dr. James King, president-elect of the American Academy of Family Physicians said, “I don't think it's a major cause for concern.”

Dr. King said he was not surprised by the survey findings, especially since it is a common practice for physicians to accept drug samples in an effort to save their patients money. Most practices are likely operating within the guidelines set out by the American Medical Association, he said. The AMA guidelines recommend that gifts should primarily have a benefit to patients and should not be of substantial value. For example, modest meals and textbooks are acceptable under the AMA guidelines, but cash payments should not be accepted.

The relationship with industry should continue to be watched and addressed, said Dr. King, who recommended that physicians review their own ethical guidelines from time to time and refuse to accept any gift that would inappropriately influence their prescribing habits.

Dr. Jack Lewin, CEO of the American College of Cardiology, called for an increase in the number of publicly funded independent reviews of drugs and devices. Increases in federal research funding would help to clarify some of the gray areas of cardiovascular care, he added.