It’s a shame that blood pressure recordings from the doctor’s office aren’t great predictors of future cardiovascular events due to white-coat hypertension, but it is what it is.

The long-recognized phenomenon is characterized by office-based BP readings that are higher and more labile than those taken during the course of normal everyday life.

Thankfully, scientists have shown that ambulatory blood pressure recording devices provide useful predictive information, particularly in those having severe hypertension, a cardiac history, multiple cardiovascular risk factors, pregnancy and elderly folks.

Now Gil Salles and co-investigators at University Hospital Clementino Fraga Filho in Rio de Janeiro, Brazil have shown that ambulatory blood pressure recordings can predict CV risk in another subset of patients, the ones with resistant hypertension.

Sales’ was a prospective study of 556 patients with resistant hypertension, defined as persistently elevated blood pressure despite treatment with 3 anti-hypertensive agents.

After median follow-up of 4.8 years, the scientists found that 109 patients (19.6%) either died or incurred a cardiovascular event.

After controlling for age, gender, prior cardiac events and other CV risk factors, Salas’ group confirmed that office-derived blood pressure recordings were not predictive of future events, but higher mean ambulatory BPs did predict these events.

Ambulatory systolic and diastolic blood pressure recordings were both effective predictors, and nighttime recordings were superior to those obtained during the day.

Physicians that use electronic medical records are less likely to pay out malpractice settlements, according to a study in the Archives of Internal Medicine

Anunta Virapongse and colleagues at Harvard Medical School surveyed a random sample of 1884 Massachusetts physicians to assess EMR utilization and obtained information about paid malpractice claims from the state’s Board of Registration in Medicine Web site.

The scientists found that 6.1% of physicians using an EMR had paid a malpractice claim, whereas 10.8% of those not using an EMR had done so. This difference was significant, but analyses including variables like gender, race, age and practice size diminished the difference. The resulting trend was not significant.

A subgroup analysis revealed that only 5.7% of frequent EMR users had paid malpractice claims, whereas 12.1% of infrequent users had done so. As above, the small sample sizes prevented the trend from achieving significance. The results therefore need to be validated before serving as a basis for policy formulation.

EMRs can reduce malpractice risk by improving follow-up of test results, reducing prescription errors and improving adherence to best practices. The exquisite documentation of care facilitated by EMRs can also help the defense in a malpractice case.
 
If these trends are confirmed, malpractice insurers could conceivably lower premiums for groups that adopt EMRs, an additional incentive to invest in the expensive systems.

Why is it that the incidence of breast cancer has gone up so dramatically since screening mammography has been introduced?

H.Gilbert Welch, Per-Henrik Zahl and Jan Maehlen developed an ingenious way to address the question and reached the almost unfathomable conclusion that some breast cancers disappear without treatment.

The scientists knew Norway’s health system adopted a biannual screening program in 1996, so they compared the cumulative incidence of breast cancer in two age-matched groups of 100,000 Norwegian women.

The first group, followed from 1992-1997, received one mammogram at the end of the observation period. The second, followed from 1997-2002, had 3 mammograms over the same time duration.

Women in the frequently screened group had a 22% higher cumulative incidence of breast cancer.

The difference could not be attributed to differential use of hormone therapy or risk factor profiles. Nor was it caused by the use of more sensitive mammograms in the latter group. The possibility that multiple mammograms somehow increase screening yields, though plausible, explained almost none of the difference and no one believes the mammograms actually caused cancer.

In commenting on the study Barnett Kramer, director of the Office of Disease Prevention at the NIH, told the New York Times, “People who are familiar with the broad range of behaviors of a variety of cancers know spontaneous regression is possible. “But what is shocking is that it can occur so frequently.”

Even if true, the astounding possibility has no immediate implications since at the time of diagnosis there is no way to tell which cancers will regress and which ones will not.

So in the end came reassurances that mammograms save lives, warnings to continue all screening programs until further notice, and a lot of people asking for more.  Like, can the study ever be replicated?

Yes, it turns out. Mexico is introducing mammography screening as we speak.

US spending on diabetes drugs nearly doubled to $12.5 billion over the last 6 years, according to a study published in this week’s Archives of Internal Medicine.

The cost escalations were driven by a 40% increase in the number of drugs prescribed per patient and a tendency to prescribe newer, costly drugs in lieu of tried-and-true generics despite safety concerns swirling around some of the newer ones.

The study investigators noted that the newer drugs Januvia (Merck, FDA approved in 2006), Avandia (GlaxoSmithKline, FDA approved 2006), and the wildly popular Actos (Takeda, FDA approved 1999) were prescribed in 28% of all doctor visits by the end of the study period.

“We need to pay attention to this,” Dr. David Nathan wrote in an accompanying editorial. Nathan, who is Chief of the Diabetes Unit at Massachusetts General Hospital, added “if you can achieve the same glucose control at lower cost and lower side effects, that’s what you want to do.”

Current guidelines for Type 2 (adult onset) Diabetes recommend metformin, a generic drug that costs about $30 per month along with dietary modifications and exercise as first-line therapy. The guidelines suggest adding other drugs for patients who fail to respond adequately, but the recommendations specifically do not include Avandia which costs nearly $225 per month.

Last year, the FDA released a safety alert for Avandia after a meta-analysis revealed an increased risk of heart attacks in patients taking the drug. There are no safety concerns of this sort for Actos or Januvia.

About 24 million Americans have Type 2 diabetes.

Physicians know the dangers of smoking, but they don’t have time to counsel patients. Toll free tobacco quit lines are a proven, cost-effective alternative, but physicians rarely refer patients to such services.

A study published in this week’s Archives of Internal Medicine has shown that paying physicians to refer cigarette-smoking patients to quit lines increases their referral rates by 250%.

The study was a randomized trial of a program offering physicians $5,000 for 50 referrals to a quit line vs. usual care (no pay for performance). Only patients who intended to quit within 30 days were eligible for referral. Physicians in the incentive program referred 11.4% of eligible smokers while those in the usual care cohort referred 4.2%.

The marginal cost per quit line enrollee was $300, a pittance given that in the US, tobacco use causes 440,000 premature deaths and $75 billion in extra medical costs per year.

The study’s authors commented that health plan collaboration was essential to program success. It streamlined referrals and allowed physicians to refer patients regardless of their insurer. Thus physicians could target all smokers rather than just those from certain health plans.

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