Family Medicine Notes

Long-time readers of my blog know that I'm a fanatic about judicious use of antibiotics. 

This case (pdf) caught my wife's eye .. and she forwarded it to me:

"... Here, in support of the allegations of negligence, gross incompetence and failure to maintain accurate medical records, BPMC presented evidence that petitioner had repeatedly prescribed antibiotics for four pediatric patients with complaints of sore, red throats without recording adequate medical histories or doing throat cultures, and despite his having made a diagnosis for which antibiotics would be ineffective. BPMC's expert established the standard of care for diagnosing such ailments in children and explained the adverse consequences of the improper prescription of antibiotics"

What's unfortunate is that this still goes on every day - and of course it feeds the expectation in our patients that antibiotics are good for sore throats.  Ugh.

Posted by Jacob Reider, MD at 05:11 PM | Permalink

This New York Times article proposes that circumcision prevents AIDS.  Of course, things are not so simple.

We agree on one point:  the spread of HIV (and other STDs for that matter) in uncicrumcised men is less than those in circumcised men.

But Tina Rosenberg's article misses the important point:  one has to get a disease in order to spread it.  So while I might agree that in some contexts - circumcision is (way) better than nothing - it is neither a vaccine, nor a good argument for universal circumcision.

Posted by Jacob Reider, MD at 10:50 PM | Permalink

technorati tags:otitis, media, sinusitis

Posted by Jacob Reider, MD at 11:14 AM | Permalink

Here's the best advice I found with a quick google search

we have found that there is some confusion as to how to correctly bill these claims. CPT code 17000, Destruction (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg. actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion, should be billed once for the first such lesion treated, when fourteen or fewer total lesions are removed or destroyed. CPT +17003 is an add-on code specifically for use with the primary CPT code 17000, only. CPT +17003, Destruction (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg. actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; second through the fourteenth lesions, each (list separately in addition to the code for first lesion), should be billed once for each additional lesion treated, up to a total of thirteen times. These two CPT codes, 17000 and 17003, can be thus combined to bill for a total of fourteen such lesions.When billing for the treatment of fifteen or more lesions, CPT code 17004, Destruction (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (eg. actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions, should be used, and only billed one time for whatever number of lesions are treated beyond fifteen. Whether fifteen or sixty lesions are treated, CPT 17004 should only be billed once for the total service, and should not be combined with CPT 17000 or 17003.For example, for destruction of seven actinic keratoses, the billing would be as follows:17000 (for first lesion)17003 x number of services = 6, for total of seven lesionsIf sixteen lesions were treated, the billing would be:17004 (billed once for 15 or more lesions)Care must be used when selecting the proper CPT code to use, as the 17xxx series codes are not always consistent. For instance, CPT 17110, Destruction (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of flat warts, molluscum contagiosum, or milia; up to 14 lesions, has no code analogous to 17000 for the first lesion. CPT 17110 is just used once for one to 14 lesions, while CPT 17111, Destruction (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), flat warts, molluscum contagiosum, or milia; 15 or more lesions, is billed once for 15 or more lesions, not in conjunction with 17110.Some procedure codes for removal or destruction of lesions are billed by size of lesion treated, while others are based on number of lesions treated. The provider should know the descriptors of the procedure codes selected, and is responsible for choosing the appropriate code to reflect what was done. This allows Medicare to pay the correct amount the first time.It has also been noted that often when multiple lesions are removed, they will all have a Pathology evaluation. In cases where benign lesions are removed for the symptomatic criteria listed on the Local Coverage Determination, and are described in the medical record as benign, it does not meet medical necessity criteria for all these to have pathology evaluations. If these are suspicious lesions, the medical necessity criteria are clearly met, but when the description in the chart states that one or more symptomatic benign lesions were removed, pathology examination may not be required and should not be billed to Medicare.

Posted by Jacob Reider, MD at 01:32 PM | Permalink

John wrote about this well done article from BBC on flu.  This year, we invested in a rapid flu test kit.  (CPT 87804)  It's excellent.  Works like a charm .. in about 5 minutes .. (yeh .. package says 10) .. and it's about as easy as a rapid strep test.  My partner diagnosed one person with flu last week .. and I saw two this week.  One was an 85 year old man who had been immunized.  So far this week .. I've used the test twice .. and both were positive.

I'm well known to be a flu-skeptic.  My kids even roll their eyes when friends or family report that they "have the flu." ... since it's almost always "a really bad cold."  .. Not the flu.

When telling patients they have a "really bad cold,"  I hope to be affirming how they feel.  they feel "really bad" and it's important that I convey that I am hearing them.  It's not "just a cold" (they hear:  get out of my office and don't waste my time) .. when I see patients with colds .. I am very careful to make sure that they know that I am taking them seriously .. that their body is working hard to get them better .. and that they don't have (fill in the blank ) .. Pneumonia or sinusitis or something that may cause me to think they would require antibiotics.

Both patients I saw this week were really really sick .. the "doc .. it hit me like a train . I had to have my neighbor drive me here" sick.  THIS is influenza. 

I'll call the health department and make sure I report these cases.

Posted by Jacob Reider, MD at 02:16 AM | Permalink

This article in the current Journal of Family Practice is hard to get at, as the site is poorly designed and only subscribers are allowed in. This is odd, since the journal is mailed free to all family physicians. Who are they really keeping out? And there are advertisements inside the site. Today I couldn't remember my password, so I clicked the little thing that told me to enter my e-mail address to have them e-mail it to me. But it didn't recognize my e-mail address. So I figger it forgot who I am .. so I went into the study and found a copy of the paper version not-yet-recycled .. found the billion-digit secret subscriber ID and typed it in. "This account is already enabled."
huh?
So then I have to go back and type in all of the e-mail addresses that I've ever had since 1997 and finally hit on one and then they e-mail me the dumb password.
This isn't how it should work. If I found the long secret number -- they should say OK and at least send an e-mail to the account associated with the number - or permit me to edit my record.
Oh ... was I posting about the poor usability? no .. sorry ..
... the article was actually quite good. It's a clinical question/answer on pharyngitis, which includes this pretty table on Centor Scores ... and a well written little review on the non-controversy on whether to do culture follow-up on rapid antigen assays:

"A retrospective outcome study reviewed the frequency of suppurative complications of GABHS among 30,036 patients with pharyngitis diagnosed with either RAD testing or throat culture. Patients included adults and children in a primary care setting. Complication rates were identical. A prospective study of 465 suburban outpatients with pharyngitis assessed the accuracy of RAD diagnosis using throat culture as a reference. The RAD accuracy was 93% for pediatric patients and 97% for adults.5 In another retrospective review of RAD testing, investigators performed 11,427 RAD tests over 3 years in a private pediatric group. There were 8385 negative tests, among which follow-up cultures detected 200 (2.4%) that were positive for GABHS. In the second half of the study, a newer RAD test produced a false-negative rate of 1.4%.7 Because of the possibility of higher false-negative RAD test rates in some settings, unless the physician has ascertained that RAD testing is comparable to throat culture in their own setting, expert opinion recommends confirming a negative RAD test in children or adolescents with a throat culture.1 Patients at higher risk of GABHS or GABHS complications may also warrant throat culture back up of RAD testing."

The money is in the pre-test probability. The nursery school teacher who called Sunday afternoon with a Centor score of 4 deserved a trip to the office to meet me and get tested (positive). The stock broker who called Saturday with no ill contacts, no kids and a Centor score of 3 was given instructions for symptom relief.

Posted by Jacob Reider, MD at 01:01 AM | Permalink

This article from this month's  JABFP reminds us that oversee of antibiotics remains a terrible problem in primary care, and family medicine especially.  The rate of antibiotic prescription for URIs decreased from 52.1% in 1997 to 41.5% in 1999:

Conclusions: Despite a downward trend in antibiotic prescribing over the years, over-prescription of antibiotics for upper respiratory infections persists. General internal medicine physicians are less likely than general/family physicians to prescribe antibiotics, but this gap seems to be narrowing. Specific interventions must be designed to address these disparities.

Family physicians prescribed antibiotics 42.9% of the time for URI .. while Internists did so 36.2% of the time.  Neither of these numbers is even approaching a reasonable goal (0%) ... I think that it's obvious that family physicians need to be better educated on this perils of over-prescribing antibiotics and given the tools to treat patients appropriately.  Of course, the CDC has some great educational tools .. but many states are working on this as well ... and the google directory  on antibiotic resistance is a good place to start looking for more information on this important topic.

Posted by Jacob Reider, MD at 12:25 PM | Permalink | Comments (6)

bedside.org: How can cellulitis of the pinna be distinguished from relapsing polychondritis? Carl discusses two presentations of a red ear. I'd add HSV. I have seen this more than a handful of times, and it is certainly high on my list of conditions that would cause a red pinna.

Posted by Jacob Reider, MD at 01:31 AM | Permalink

A year ago I posted about many commercial nasal sprays and how they may contain preservatives that can actually destroy neutrophils.
Since then, I've told patients to make it at home. Here's the secret formula:

• 1 Teaspoon of Baking Soda


• 1 Teaspoon of salt


• 1 Cup of warm water

The solution can be squirted up the nose from a squeeze bottle .. or you can just dip a teaspoon in the solution, place it under one nostril and hold the other nostrol closed ... and snort it up. Yep .. if feels like you just went bodysurfing on a big Atlantic wave .. invigorating. Nasal saline is now a mainstay of my treatment for nasal complaints. I rarely use antibiotics. This article reviews the use of nasal saline and concludes:

"Summary: Nasal irrigations should no longer be considered merely adjunctive measures in managing sinonasal conditions. They are effective and underutilized. Some of the persisting unanswered questions will only be answered by further research."

Posted by Jacob Reider, MD at 06:33 PM | Permalink

Longtime Docnotes readers know that I am a fanatic about antibiotic overuse.  This relegion applies not only to WHETHER an antibiotic is prescribed, but which one.

I did a research project during my residency in which I demonstrated that physician prescribing practices are influenced by "detailing" as the pharmaceutical industry knows well.  But I detailed generic medications.  So over the course of a winter, I taught my colleagues about erythromycin, TMP/SMX (Bactrim) and amoxicillin.  How to dose them, what they are effective for, etc etc.  ... and through a grant from two local health plans, I purchased samples from the hospital pharmacy of these medications and placed them in the samples cabinet.

The results were that not only did the physicians give out more samples of the generic medications ... but that they wrote more prescriptions for them as well.

Like many of my little adventures (yes .. I'll finish cleaning the basement "real soon now") ... this one was never finished to the degreee that would make it a publication-quality paper  ... but it was a fun and instructive project nonetheless.  A core part of the eduction .. even back then (1996) was that the 1st line treatments for the most common conditions are NOT the higher priced "big guns."  As the physicians built experience with seeing patients get better with inexpensive narrower spectrum agents ... a lifetime of better prescribing practice was (I hope) built.

Fast forward to 2004.

Well established protocols now exist for the treatment of community acquired pneumonia .. and most of them suggest that "a macrolide or doxycycline" be a component of the therapy. (or a newer quinolone .. but don't get me goin about them!)

There is rather little data to guide us in this choice, and despite ample marketing, and a significant difference in price, my choice predicably remains doxycycline.  Azithromycin seems a popular choice for many other physicians .. and I think that the sense of security they get from the much broader spectrum helps physicians sleep better at night .. knowing that this medication "gets all those bugs."

But the "getting them all" mentality is not consistent with good, thoughtful practice.  We need to treat with as NARROW a spectrum as possible .. and really think hard about what the likely organisms are ... not just shoot from the hip (with a shotgun) and hope that what's there is wiped out.

Challenged this morning by a thoughtful colleage to provide evidence for the long 1/2 - life of azithromycin correlating with clinically important increases in resistance (I often quote studies that demonstrate tissue levels of azithro persisting below MIC even 3 - 4 weeks after treatment is discontinued, which theoretically would account for significant resistance pressure) ... I've come up with a few papers that suggest that such a correlation does in fact exist:

Streptococcus pyogenes resistance to erythromycin in relation to macrolide consumption in Spain (1986–1997)

Juan J. Granizo^a, Lorenzo Aguilar^b,*, Julio Casal^c, Rafael Dal-Ré^b and Fernando Baquero^d

Posted by Jacob Reider, MD at 04:15 PM | Permalink

According to this POEM - there is no difference between Azithomycin and Amox-Clav in the treatment of otitis media.

Bottom line
For every 10 children with persistent or recurrent otitis media who get high-dose azithromycin for 3 days instead of high-dose amoxicillin-clavulanate for 10 days, there is one additional clinical cure at 1 month and 1 less episode of diarrhea. There is no difference, however, in clinical success at 2 weeks. (LOE = 1b)

But where's the placebo group?  The study referenced above

A reminder that Chris Cates' EBM website has excellent resources on otitis media. 

It's odd - because I do recall seeing many cases of recurent otitis when I was in residency - and even when I was at the Albany Medical Center residency program - where I was on the faculty.  But in my current practice, my  colleagues and I are so conservative with antibiotics that we rarely treat kids who present initially.  We're seeing fewer cases overall - and fewer cases of resistant otitis and VERY few cases of recurrent otitis.  I can't think of the last kid I referred to ENT. 

Questions for the literature:

• Do delayed prescriptions reduce antibiotic prescriptions?  Yes
• Is there a way to clinically predict which organism is causing an episode of otitis? YES (cool!) (viruses?)
• Why does AOM cause persistent OME?
• Are there well established international guidelines?  No

Posted by Jacob Reider, MD at 08:24 PM | Permalink

Save Antibiotic Strength (SAS-NY) is a very good website if you're looking for materials on careful antibiotic prescribing.

It's a VERY poorly designed website, though .. and this detracts from the message.  Too bad.  Just in time for Jakob's Top Ten Web Design Mistakes of 2003. I agree with most of them.

Posted by Jacob Reider, MD at 01:31 AM | Permalink

It's that time of year again ... and we're seeing kids in the office with otitis media. With each pasing year, more parents seem to understand that antibiotics for acute otitis media in children are largely unnecessary.

Several years ago, I developed a guideline that was part of a regional effort to reduce antibiotic overuse.   I still print out the patient information that we developed as part of this project, but these days I find that parents already know much of the contents.

When making the decision of how to treat a child with otitis these days, I find myself sharing the decision with the parents. 

JMR:  "Well .. 80% of kids in this situation will get better by themselves."

Mom: "Yes .. it seemed to work last time.  Johnny got better in 2 days .. but the time before that, he needed the antibiotics."

JMR: "Well, that's the problem .. we don't yet have a way to twll which kids are going to be that 20%"

Mom: "Let's wait and see.  I'll call you in 2 days if he's not better."

On Fridays and before holidays, I usually write the prescription, and ask the parents to hold on to it for a day or two.  It's not uncommon that they bring it back to demonstrate proudly all was well without the antibiotics.

In this process, I always focus on the concept that otitis media, like sinusitis, is a problem with obstruction .. rather than one of infection.  There's a nice monograph on this topic.   Te bugs are there anyway.  A little H. flu, S. Pneumo and Moraxella are components of the normal flora of the nasopharynx and therefore the eustacian tube.

But as the mucosa thickens in the context of a cold, the bugs are trapped.  A system that is usually dynamic and flushed on an ongoping basis .. is now stagnant.  Warm, moist place with bacteria.  Infection?  Duh.  But as with any abcess .. we need to enhance drainage FIRST .. not necessarily treat with antibiotics.

Too bad we can't just pop open the eustacian tubes with a remote control.  Hmm ... maybe I'm not the only one with this idea.

Reviewing the last 20 cases of otitis media that I saw in the office .. I wrote prescriptions for antibiotics in 6 of them within 48 hours of the visit.  Many of these prescriptions were on Fridays .. so I don't really know how many kids actually got the antibiotics.   I wonder how Chris Bradley or Enoch  or Bhavesh handle this in urgent care settings. 

In our area .. urgent care and ERs have been the biggest problems for us in curbing antibiotic oversue.  Patients seem to get what they ask for in such settings .. which then builds the expectation that antibiotics are indicated for sinusitis, otitis or bronchitis ... and of course, this is a concept that I don't agree with.

In the context of the recent flu scares .. and a rather persistent "flu-like-illness" that has been quite prevalent in the past 2 weeks (though waning now, it seems) ... I spoke on the phone with a friend in the ER the other day:

JMR: "How are you guys dealing with this high-fever/cough viral thing going around?"

ERDOC: "Man .. it's bad.  Clearly not flu .. but most people think it is ... which is just semantics, I guess.  The worst part is that many of the urgent care docs are prescribing Azithromycin for it ... so the patients come here 3 days later because the z-pak isn't working and they want us to give them a stronger antibiotic"

JMR: "yikes."

Posted by Jacob Reider, MD at 01:46 AM | Permalink | Comments (1)

Flu-shot shortage may aid MedImmune

This is a no-brainer.  We're out of vaccine, and only one local pharmacy carries the stuff. 

Who killed JFK? 

Is the Flu crisis of 2003-2004 real?

Another Oliver Stone Movie?

Posted by Jacob Reider, MD at 12:30 AM | Permalink | Comments (1)

Well, in the context of writing not one but TWO prescriptions for antibiotics in the last 24 hours (long-time readers will recall that I am a fanatic about the overuse of antibiotics and I write for them very rarely)

This time, I had a reason.

Our local version of the pertussis outbreak has become signifiant.  With 21 confirmed cases in a high school about 4 miles from our office, I treated a coughing student from that school this morning after consultation with the health department.   But last night's customer was a textbook case.  The PCR's will be back in a few days. We'll see.

In realted news ...

This study in JAMA confirms that a shorter duration of antibiotics may be better in the ICU:

• CONTEXT: The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown.
• Shortening the length of treatment may help to contain the emergence of multiresistant bacteria in the intensive care unit (ICU).
• RESULTS: Compared with patients treated for 15 days, those treated for 8 days had neither excess mortality (18.8% vs 17.2%; difference, 1.6%; 90% confidence interval [CI], -3.7% to 6

Posted by Jacob Reider, MD at 12:21 AM | Permalink