Docnotes

Physician Loses License for Prescribing Antibiotics

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.

Ny Times on Circumcision

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.

NNT Online: Sinusitis, otitis, pharyngitis

Long before I met Bill Heuston - I knew I would like him. He's done great research and is very organized. (an asset I envy) Chris Cates is the same - yest I have yet to meet him to validate that opinion. Christ posted a great summary page on Treatment of common infections - December Newsletter 2006 It's a must-bookmark/digg, etc.

technorati tags:otitis, media, sinusitis

How to bill 25 molluscum lesions on the belly?

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.

Influenza is here!

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.

 

Centor Scores, etc

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.

Antibiotic Prescribing - Still too much

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.

DDX of Pinna cellulitis

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.

Make Saline Spray at Home

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."

Macrolide Resistance

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-R^b and Fernando Baquero^d

... From a pharmacodynamic point of view, other factors may have contributed to the selective process. It has been suggested that macrolide agents with low C_max and long half-life (like bd or od macrolides) are likely to produce a longer selective window, which means longer bacterial exposure to resistance-selective concentrations.³² Long-acting agents optimize selective effects.³³ In any case, either directly or indirectly, both bd and od macrolides appear to be the main reason for the increase in erythromycin resistance.

^{Read the whole paper .. as it's a great overview of an issue that is complex .. and quite scary.  The authors are careful to avoid saying that there is clarity of causality (since correlation can never clearly determine causality) .. but this is certainly enough to support the hypothesis that there is a relationship.}

^{There are other reports (here and here) that discuss the correlation between macrolide use and increaseing resistance .. and of course the well known study that demonstrated decreased resistance as macrolide use decreases.}

^{The CDC's report on this highlights an alarming increase:}

azithromycin and clarithromycin, +388%; quinolones, +78%; and amoxicillin/clavulanate, +69%. This increasing use of azithromycin, clarithromycin, and quinolones warrants concern as macrolide- and fluoroquinolone-resistant pneumococci are increasing.

... and this paper sums it up rather well: (my emphasis added)

... Antibiotic use in ambulatory patients is decreasing in the United States. However, physicians are increasingly turning to expensive, broad-spectrum agents, even when there is little clinical rationale for their use.