Archive for September 15th, 2008

OA of the knee? Try Meds and PT

September 15th, 2008 | No Comments | Source: Medical News Today, NEJM, NY Times

A randomized controlled trial has revealed that for patients with osteoarthritis (OA) of the knee, arthroscopic surgery offers no benefit versus conservative therapy.

The arthroscopic intervention tested in this study is lavage and debridement. Conservative therapy included anti-inflammatory medications and physical therapy.

The investigators randomized 178 patients with moderate to severe OA. They assessed patient outcomes using two symptom-based questionnaires-the Western Ontario and McMaster Universities Osteoarthritis Index and the Short Form-36 Physical Component summary score. When investigators compared scores on these tests for the treatment and control groups at the end of two years, they found no significant difference. In particular, there was no difference in pain or activity level. Score comparisons at earlier time intervals also showed no difference.

The authors concluded that “the resources currently allocated towards arthroscopic surgery for osteoarthritis would be better directed elsewhere.”

Interestingly, Medicare stopped paying for the procedure in 2003 after an earlier study had come to the same conclusion, despite protests from many surgeons who felt the trial design was flawed. It is not clear how many arthroscopic surgeries for OA had been done between then and now (and presumably billed for using a reimbursable procedure code), but the number is probably in the hundreds of thousands per year.

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Retail Clinics to the Rescue

September 15th, 2008 | No Comments | Source: Health Affairs

Just as some reached for bullhorns to pronounce a crisis in the US health care system because of the worsening shortage of general internists, along comes a new option for people who want primary care—the retail clinic.

Retail clinics are low budget, low profile affairs staffed primarily by nurse practitioners and housed in places like Wal-Mart and CVS. They are to be distinguished from urgent care centers which are larger in size, freestanding, staffed by physicians and others, and equipped to manage a slightly higher level of care (e.g. suturing lacerations).

Can retail clinics help avert the crisis mentioned above? Yes and no.

No, because a study published in Health Affairs this week finds that 90% of visits to retail clinics are for simple things like sinusitis, blood pressure checks and immunizations. These problems constitute only 13% of visits to general internists, 30% of visits to pediatricians and 12% of visits to emergency rooms. The study shows that retail clinics cannot match the spectrum of services offered by primary care physicians.

Yes, because 60% of visitors to retail clinics do not even have a primary care provider. One third of them are uninsured altogether. These people can now get at least some inexpensive primary care services at a convenient time and place, whereas in the past they either got nothing or found themselves waiting forever to be seen in an emergency room.

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US Disregards Pakistan’s Sovereignty

September 15th, 2008 | No Comments | Source: NY Times, Washington Post

In July, President Bush secretly authorized new rules of engagement allowing US Special Operations forces to conduct ground attacks within Pakistan. Bush did not notify the Pakistani government or its military before signing the orders.

News of the strategic shift follows a highly publicized US helicopter attack 10 days ago against a village 20 miles inside Pakistan’s border. The attack killed a handful of al Qaeda operatives and many civilians. Bush’s move was quickly denounced by Prime Minister Yousaf Gillani, who heads Pakistan’s first democratically elected government in 10 years.

Pakistan’s military chief, Gen. Ashfaq Parvez Kayani leveled harsh criticism as well. “No external force is allowed to conduct operations inside Pakistan” he said, adding that his forces would defend Pakistan’s sovereignty “at all costs.” 

(more…)

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