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Report: Gout Vastly Undertreated in USA & UK

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Gout, the most common inflammatory arthritis worldwide, is treatable but vastly undertreated, according to epidemiologic studies that now encompass three continents. The undertreatment problems previously reported in the United Kingdom and the United States also characterize gout in Taiwan, according to a nationwide population study.

Chang-Fu Kuo, MD, from the Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, United Kingdom, and the Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, and colleagues report the study results in an article published online January 23 in Arthritis Research & Therapy. Dr Kuo was also the lead author on the UK study.

In the new article, Dr Kuo and colleagues report, although gout incidence in Taiwan decreased during the course of the study, prevalence remained high and stable and gout management remained poor, with only about one quarter of patients receiving potentially curative urate-lowering therapy.

Jasvinder A. Singh, MD, MPH, who led the US study and who was not involved in either the Taiwan or UK studies, told Medscape Medical News, “The rates of undertreatment of gout in the US are also quite high and have been widely published, and many of the observations published in this study have also been seen in many other countries. Undertreatment includes not only lower rate of use of urate-lowering drugs but also infrequent monitoring of the serum urate and a low proportion reaching the target serum urate of less than 6 mg/dL due to use of suboptimal dose of urate-lowering drugs.” Dr Singh is professor of medicine at the University of Alabama, Birmingham.

Dr Kuo and colleagues used data from the National Health Insurance Research Database for Taiwan, which covers the entire population of 23 million people, to identify gout patients, estimate prevalence and incidence for each year from 2005 to 2010, and examine patterns of gout treatment.

Gout prevalence was 1,458,569 (6.24%), and gout incidence was 56,595 (2.74/1000 person-years). Gout prevalence did not change significantly during the study, although gout incidence decreased 13.4% between 2005 and 2010 and 2.1% between 2007 and 2010. In comparison, estimates of annual incidence in US studies ranged from 0.45 to 1.73 per 1000 person-years.

Gout was most prevalent and had the highest incidence rates in eastern coast counties and offshore islets of Taiwan, which the authors note also have higher populations of indigenous Taiwanese. “However, genetic factors account for just one-third of phenotypic variation of gout in men and only one-fifth in women so environmental factors could also contribute to the variable geographical distribution of gout in Taiwan,” the authors write.

“To the best of our knowledge, our study is the first to report gout incidence in Asian populations. The incidence in Taiwan was much higher than other countries, suggesting significant racial and geographic variation in the aetiology of gout,” they add.

Dr Singh commented, “There are very few studies of gout risk in Asian patients in the US, so it’s not easy to say whether the problem is better, the same, or worse than Taiwan. There are no particular subgroups in the US that require particular attention, except that African-Americans have been shown to have poorer outcomes with gout compared to Caucasians, and lower rates of medication treatment.”

In the Taiwan study, in 2010, only about one third of patients with gout had contact with health services in relation to gout, and only one in five were prescribed urate-lowering therapy. Of those treated, 60.08% (95% confidence interval, 59.91% – 60.25%) received uricosuric agents alone, 28.54% (95% confidence interval, 28.39% – 28.69%) received a xanthine oxidase inhibitor, and 11.38% (95% confidence interval, 11.27% – 11.49%) received both. The authors add, “Unfortunately, this suboptimal care has not changed over the study period, despite the publication of national and international guidelines on gout management during this period.”

The authors have disclosed no relevant financial relationships. Dr Singh reported no financial conflicts related directly to this study but has received research and travel grants from Takeda and Savient and consultant fees from Savient, Takeda, Regeneron, Allergan, and Novartis.

Source: Janis C. Kelly, Medscape

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What is driving a physician shortage and how can it be stopped?

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As its name insists, the Affordable Care Act (ACA) is supposed to give more American access to reasonably-price healthcare, but this affordability would prove fruitless if the number of primary care physicians in the United States continues to decrease.

Recent findings from the likes of SERMO, the largest online community of physicians, show that amongst all provider specialties family and internal medicine are two of three unhappiest groups of physicians, 62 percent and 60 percent, respectively. Only obstetricians and gynecologists come in lower at 59 percent. For internists and family physicians, dissatisfaction with lifestyle was a common factor leading many to rethink their choice of specialty, 25 and 23 percent, respectively.

“These are the doctors on the front lines in medicine who are seeing the increase pressure and in particular now with the ACA in play and a higher stream of patients coming in,” SERMO CEO Peter Kirk tells EHRIntelligence.com. “It is still a challenging work environment and they are at the lower end of the pay scale. Those are the ones looking to change whereas those on the higher end of the pay scale — orthopedists, physiatrists, oncologists, etc. — are happiest with their professions.”

Although these physicians admit to dissatisfaction with their choice of specialty, it does not mean that they are leaving it for another. So then why is this problematic? The answer to that question is seen in the choices made by the next waves of physicians, residents, who are opting more lucrative and less stressful professional positions.

“Based on some of the conversations on the site, you can build a sense of how much there is a drive toward specialty right off,” Kirk explains. “Having your own private practice as a primary care physician is not the dream anymore. It doesn’t pay the bills. There’s too much complexity, too much involved in running a business. This is driving residents into searching for the best-paid specialties in order to help pay of their debt and have a nice head start moving forward.”

Here lies the basis on predictions that physician shortages are only a matter of time. The ACA and increase of insured Americans should only serve to exacerbate the stresses associated with primary care.

“There will not be enough real doctors at the front lines of primary care to handle the workload, especially with the ACA adding 30 million additional patients to the system,” maintains SERMO’s CEO. “More pressure and more of the primary care are being assigned to non-physicians. The NPs and PAs are likely to do more of the work. That’s going to play out over the next five to ten years.”

A solution to the problem?

The physician shortage problem is real, but what can be done about it? Both the Association of American Medical Colleges (AAMC) and American Medical Association (AMA) believe the solution to be found in graduate medical education.
Crediting medical schools for increasing enrollments and students for responding with an increasing number of applications, the AAMC is placing the onus on lawmakers:

Now Congress must do its part by lifting the cap on the number of federally supported residency training positions. Lawmakers have responded with proposals in the House and Senate to increase the number of residency positions. But they must act now in order to ensure that there are enough physicians for our growing and aging population.

Meanwhile, the AMA has developed a new policy to encourage state and federal legislators and private payers help fund residents in training with an emphasis on promoting the teaching of team-based and patient-centered care models by accrediting associations.

Through its Accelerating Change in Medical Education initiative, the AMA has convened nearly a dozen medical schools to decrease disparities in medical education. “As more patients continue to receive health care coverage, it is essential that the next generation of physicians is sufficiently trained,” said AMA Board Member Stephen Permut, MD.

Health information technology (IT) has a role to play in easing the burdens on providers if developed, implemented, and used properly. But it is still only a support and no substitute for the skill and expertise of physicians using it.

Source:
Kyle Murphy, PhD
EHR Intelligence

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Fashionable Footwear – Good for Style, Bad for Foot Health

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More than half of Americans suffer from foot problems, and often those problems are directly related to shoes.

But no matter how cute a shoe looks, Orly Avitzur, medical adviser at Consumer Reports, said that having fashionable footwear isn’t worth the health risks.

“Wearing the wrong shoes can lead to lifelong deformities that require surgery to fix,” she said.

According to a new study from the Institute for Preventive Foot Health, uncomfortable and ill-fitting shoes are a serious problem. Shoes that force feet into narrow or pointy toes can cause bunions or hammertoes, where the toes curl unnaturally downward.

But that doesn’t stop women like Trisha Calvo and Jennifer Frost from wearing name brand heels.

“I feel fabulous in them,” Frost said. “You feel fabulous in your shoes…not physically
fabulous in them.”

Studies show that high heels can shorten your Achilles tendon and can trigger planter fasciitis, an inflammation in the soles of the feet. Avitzur recommends foregoing high heels for something more comfortable.

“Opt for a lower heel to take some of the pressure off the ball of your foot,” she said. “Make sure that there is enough room in the toe, and avoid thin-soled shoes that have little or no support.”

But even flat shoes can hurt feet if they lack proper support and cushioning, especially if they’re the wrong size.

One recent study revealed that up to a third of people wear the wrong shoe size, sometimes by up to one-and-a-half sizes. To combat that problem, Consumer Reports recommends measuring your feet each time you buy, especially for people over 40. After that, feet can grow up to half a shoe size every 10 years.

Source:
WRAL

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What’s at stake if Congress repeals the Medical Device Tax?

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During the battle to reopen the government, a pot
With that in mind, here are some frequently asked questions about the tax.

Q: What is the medical device tax?

A: Since the beginning of this year, medical device manufacturers and importers have paid a 2.3 percent tax on the sale of any taxable medical device. The tax applies to devices like artificial hips or pacemakers, not to devices sold over-the-the counter, like eyeglasses or contact lenses.

Q: Why did Congress put the tax into the health law?

A: The law created a package of new taxes and fees to finance the cost of the health law’s subsidies to help purchase coverage on the online marketplaces, or exchanges, and the law’s Medicaid expansion. In addition to the tax on medical devices, an annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion. In 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. That has been dubbed a “Cadillac” tax because it hits the most generous plans.

Q: Why do proponents of the repeal suggest the medical device manufacturers should get a break over those other industries?

A: Medical device makers say the tax will cost 43,000 jobs over the next decade and will increase healthcare costs. In a September letter to lawmakers, device manufacturers said if the tax were not repealed, “it will continue to force affected companies to cut manufacturing operations, research and development, and employment levels to recoup the lost earnings due to the tax.”

The device makers also assert that, unlike other health industry groups that are being taxed through the health law, they will not see increased sales because of the millions of people who will be getting insurance through the overhaul. “Unlike other industries that may benefit from expanded coverage, the majority of device-intensive medical procedures are performed on patients that are older and already have private insurance or Medicare coverage. Where states have dramatically extended health coverage, such as in Massachusetts where they added 400,000 new covered lives, there is no evidence of a device ‘windfall,'” the group’s letter to Congress stated.

The left-leaning Center for Budget and Policy Priorities has challenged industry assertions that the tax will lead medical device manufacturers to shift operations overseas and that it will reduce industry innovation. Since the tax applies to imported and as well as domestically produced devices, sales of medical devices in the U.S. will be subject to the tax whether they are produced here or abroad, the center’s analysis notes. Innovation in the medical device industry has slowed for reasons unrelated to the tax, the center said, noting that the health law may spur medical-device innovation by promoting more cost-effective ways to deliver care.

Q: Who else is pushing for a repeal?

A: Republicans and Democrats in both chambers – in particular those who hail from states with many device manufactures, such as Minnesota, Massachusetts and New York — have sought to repeal the medical device tax. Most recently, Sen. Susan Collins, R-Maine, has pushed for a repeal as part of larger legislation to lift the debt ceiling and reopen the government.

The Republican-controlled House has twice passed legislation to scrap the tax, including a recent measure that would have also delayed implementation of the health law by a year. In the Senate, 33 Democrats and Maine Independent Angus King voted earlier this year to repeal the tax, although the vote was a symbolic one, taken as part of a non-binding budget resolution.

Q. Who opposes the repeal?

The White House in the past has said the president would not support such a measure, although it has not commented about the issue in the current negotiations. In a statement issued last year about a congressional effort to get rid of the tax, the White House said, “The medical device industry, like others, will benefit from an additional 30 million potential consumers who will gain health coverage under the Affordable Care Act starting in 2014. This excise tax is one of several designed so that industries that gain from the coverage expansion will help offset the cost of that expansion.”

Senate Majority Leader Harry Reid, D-Nev., has said that the Senate will reject any attempts by Republicans to delay implementation of the law or to repeal the medical device tax as part of reopening the government or lifting the federal debt ceiling. But it is unclear if he would still oppose the effort if it was part of a major bipartisan compromise on the health law and budget issues.

Meanwhile, other health care providers are watching closely. In a recent blog post, Chip Kahn, president and chief executive officer of the Federation of American Hospitals, an association of for-profit institutions, wrote that if Congress reopens the heath law “to reconsider the contributions of any one health care sector that benefits from ACA’s coverage expansion, it should simultaneously address the changed circumstances of hospitals and provide similar relief.”

Source: Mary Agnes Carey, Kaiser Health News/Healthcare Finance News

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“We Shouldn’t Be Doing It”: Lecturer Calls Out Serious Podiatric Myths

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During his lecture entitled “Righting the Wrong: Exploding Myths in Podiatric Medicine” last month, Bradley W. Bakotic, DPM, DO, Bako Pathology Services in Alpharetta, GA called out some myths which have inexplicably become part of the modus operandi of the modern podiatrist.

“Podiatry is a little bit incestuous,” Dr. Bakotic said. “If you go to MD school, you’re taught dermatology by a dermatologist. In podiatry, you’re often taught dermatology by a podiatrist who has an interest in dermatology. It’s incestuous in the sense that we don’t get out into other disciplines like we should. We pass on ideas, and sometimes they’re frankly wrong.”

The first myth Bakotic tackled was “Soft tissue mass? Just cut it out!” school of thought.

“That’s a big one” he continued, “It’s profession-wide and can actually end up in frank negligence. I think this came from the fact that 70 percent of pedal soft tissue masses are ganglia, which are pseudo cysts. The problem is other neoplasms happen.”

“If you just cut it out blindly, you almost never have appropriate margins, so you’re going to have a higher recurrence rate,” he said. “It almost doubles. Distant metastasis also almost doubles.”

Bakotic went on to state the potential litigative repercussions of this; “When you go in and cut out soft tissue mass with positive margins, you cannot do limb-sparing surgery in the aftermath,” he said. “It has big repercussions.”

His conclusion on the myth was strong; “Cutting out soft tissue mass is something that should be left behind in this profession, we shouldn’t be doing it. We hurt people.”

Dr. Bakotic continued to dispel another myth – that acral dermatitis should be seen as tinea pedis until proven otherwise.

“When I was practicing podiatry, I wrote [a prescription] for one corticosteroid in seven years,” he said. “That’s incompetence. I was led to believe every time you saw a rash on the foot, it was tinea.”

Like many podiatric physicians, Dr. Bakotic said, he commonly writes prescriptions for antifungals.

“If you get the prescription data, you’ll see it’s an absolute fact. Only 25 percent of podiatrists prescribe a topical corticosteroid at least once a month. That’s ridiculous.”

After sharing results of studies that show nearly two-thirds of skin biopsies thought to be tinea pedis are not, Dr. Bakotic shared 10 photos with the audience, asking them to identify how many were cases of tinea pedis.

The answer? None.

“Many of us were just taught to assume everything’s a fungal infection,” Dr. Bakotic said. “When I was a student, if someone came in with dermatitis I was already running to the cabinet with the Spectazole samples.”

Source:
APMA

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Healthcare Hiring Continues to Increase

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According to Healthcare Finance News the healthcare industry has continued to grow, increasing by 23,400 positions last month.

The biggest growth area were in ambulatory healthcare settings and at hospitals specifically in home healthcare services, which added 6,800 jobs. Physician offices added 1,000 jobs, while outpatient care centers boosted employment by 3,200 jobs and overall, hospitals job positions rose by 7,900.

Nursing and residential care facilities also increased hiring in March, although at a much slower pace, adding 200 jobs.

Source:
Healthcare Finance News