Jane Neff Rollins

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few studies have assessed how many ambulatory care practices in the United States use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers.

Both of the studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. As Dr. Simon's study found, small practices with fewer than seven physicians were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

Overall, about 20%–30% of practices in Massachusetts have EHRs, but adoption rates are lower in smaller practices. Larger practices may have the money and staff expertise to overcome the financial and technical barriers.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few studies have assessed how many ambulatory care practices in the United States use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers.

Both of the studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. As Dr. Simon's study found, small practices with fewer than seven physicians were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

Overall, about 20%–30% of practices in Massachusetts have EHRs, but adoption rates are lower in smaller practices. Larger practices may have the money and staff expertise to overcome the financial and technical barriers.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to two surveys presented in posters at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few studies have assessed how many ambulatory care practices in the United States use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians, and Madeline McCarthy from Partners Healthcare System Inc., also in Boston, surveyed practice managers.

Both of the studies were done in Massachusetts in 2005, and both revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

In Ms. McCarthy's study, 29% of practice managers reported using EHRs in their practices: 26% of primary-care-only and 28% of specialty-care-only practices had adopted EHRs, compared with 40% of multispecialty practices. As Dr. Simon's study found, small practices with fewer than seven physicians were significantly less likely to have EHRs than were practices with more than seven physicians.

Practices that had computerized claims and/or billing systems, computerized scheduling systems, or computerized prescribing systems were significantly more likely to have also adopted EHRs than were practices without such systems.

Among practices in which EHRs allowed computerized retrieval of laboratory and radiology results, 88% of practices reported that a majority of their clinicians actively use these features. Also, survey responses showed that in 72% of practices with electronic decision support, the majority of clinicians actively use that feature.

The findings showed that among the practices that do not currently use EHRs, the majority plan to implement them within 3–5 years. Surprisingly, however, 37% of practices did not plan to establish EHRs in the foreseeable future. Cost was the most frequent (50%) reason given for not implementing EHRs.

Although both surveys were limited in that the study population was from a single state, they did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

Overall, about 20%–30% of practices in Massachusetts have EHRs, but adoption rates are lower in smaller practices. Larger practices may have the money and staff expertise to overcome the financial and technical barriers.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to survey findings presented as a poster at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians practicing in Massachusetts in 2005. The findings revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

Although the survey was conducted in a single state, it did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to survey findings presented as a poster at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians practicing in Massachusetts in 2005. The findings revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

Although the survey was conducted in a single state, it did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — Cost is the most frequently cited barrier to adoption of electronic health records, according to survey findings presented as a poster at the annual meeting of the Society of General Internal Medicine.

Although electronic health records (EHRs) appear to increase the efficiency and quality of medical care, few published studies have assessed how many ambulatory care practices in the United States currently use EHRs.

Dr. Steven Simon and his team at Harvard Medical School, Boston, conducted a survey of physicians practicing in Massachusetts in 2005. The findings revealed barriers to making a smooth transition from paper-based record systems to EHRs.

Overall, 23% of physicians who responded to the Harvard survey used EHRs in their practices—most of them (58%) for at least the previous 3 years. A larger proportion of multispecialty practices (35%) than primary care practices (25%) were using EHRs. Larger practices (seven or more physicians) were more likely to adopt EHRs than were solo practices (57% vs. 15%). Hospital-based practices or those with computerized office systems were also more likely to use EHRs.

Barriers to adopting EHRs identified by survey respondents included start-up costs (75%), maintenance costs (72%), loss of productivity while learning (73%), lack of computer skills (57%), skepticism about benefits (54%), and privacy or security concerns (48%). Physicians who listed start-up costs and loss of productivity as reasons not to adopt EHRs were significantly less likely to use EHRs in their practices.

Although the survey was conducted in a single state, it did target practices that varied widely in terms of number of physicians, specialties, hospital associations, and urban vs. rural location.

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug therapy, compared with 4% before the trial. However, there was no significant difference between intervention and control groups in the management of dementia. The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” he said.

Patient education materials for each condition were in each exam room, so the physician didn't have to leave the room and interrupt the flow of the visit. For example, if a patient had problems with falling, the doctor might check the referral box for tai chi classes and pull a list of classes organized by zip code from the rolling cart that was in every room.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, has been made available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug therapy, compared with 4% before the trial. However, there was no significant difference between intervention and control groups in the management of dementia. The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” he said.

Patient education materials for each condition were in each exam room, so the physician didn't have to leave the room and interrupt the flow of the visit. For example, if a patient had problems with falling, the doctor might check the referral box for tai chi classes and pull a list of classes organized by zip code from the rolling cart that was in every room.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, has been made available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — A practice-based, paper-and-pencil-based intervention can improve quality of care for community-based vulnerable elderly patients with dementia or incontinence, Dr. David B. Reuben reported at the annual meeting of the Society of General Internal Medicine.

The Assessing Care of the Vulnerable Elders (ACOVE-2) trial, funded by Pfizer and Rand Health, was implemented in two large group practices in California with patients aged 75 years and older who had dementia or incontinence. The intervention group included 357 patients, and the control group had 287 patients, said Dr. Reuben, director of the multicampus program in geriatric medicine and gerontology at UCLA.

Study sites included a primary care practice with 30 physicians serving 22,000 patients (67% of whom were in managed care programs) and a multispecialty practice with 100 physicians and 140,000 patients (50% in managed care programs).

The ACOVE-2 sites in the intervention group redesigned their practices to identify eligible individuals, collect data, develop structured visit notes to suggest appropriate care, provide patient education, and link patients to community resources.

The structured visit notes were filled out by the physician. For example, the visit note for preventing falls included check boxes for testing vision, gait, and balance. The dementia visit note included check boxes for long- and short-term memory, a simple math question about making change for a purchase, and a language-related question. After the intervention, overall care patterns improved: 45% of patients at risk for falls received a specialty exam and 89% received recommendations to improve strength/gait problems, compared with 12% and 58%, respectively, before the intervention.

In addition, after the intervention, 33% of patients with incontinence received a recommendation for behavioral treatment before drug therapy, compared with 4% before the trial. However, there was no significant difference between intervention and control groups in the management of dementia. The structured visit notes included check boxes to minimize the time needed to fill out each section. “If it was quick, we knew doctors would do it. If it took time, doctors wouldn't do it,” he said.

Patient education materials for each condition were in each exam room, so the physician didn't have to leave the room and interrupt the flow of the visit. For example, if a patient had problems with falling, the doctor might check the referral box for tai chi classes and pull a list of classes organized by zip code from the rolling cart that was in every room.

“I think the most interesting and controversial aspect of patient education material was the follow-up sheet,” Dr. Reuben said. The follow-up sheet included patient instructions for treatment and a list of questions for the patient to answer as homework before the next visit.

Physicians may encounter problems adapting ACOVE processes to their own practices, Dr. Reuben said. “One thing I can guarantee. If you try to do this exactly how it was done, it won't work or you won't do it. You must ask 'what can I do to tweak it?'”

More information about ACOVE, including forms and physician and patient education materials, has been made available at www.geronet.ucla.edu/centers/acove/index.htm

LOS ANGELES — Fears about personal safety appear to be a barrier to exercise among older African Americans in low- and moderate-income areas of Los Angeles, Dr. O. Kenrik Duru reported at the annual meeting of the Society of General Internal Medicine.

While developing a community-based physical activity intervention for older African Americans, the investigators conducted six focus groups in Los Angeles during 2004 and 2005 with a total of 59 African Americans aged 60 years and older. The subjects were from four senior centers that had significant African American populations—two in a low-income area and two in moderate-income areas. In each center, investigators recruited a convenience sample of interested ambulatory seniors.

The participants averaged 66 years old and 75% were female; 59% had graduated from high school, and 71% had annual incomes of less than $10,000, said Dr. Duru, a third-year National Research Service Award fellow at the University of California, Los Angeles.

Many participants reported exercising three to seven times weekly, but often the duration was short (10–15 minutes). Residents of both low- and moderate-income neighborhoods preferred indoor activity, such as low-impact aerobics, to outdoor activity. Although participants consistently mentioned a concern for physical safety, other reasons for preferring the indoors included availability of air conditioning and restrooms, and the avoidance of bugs.

Participants in low-income neighborhoods worried most about things they had seen in their neighborhoods, such as gang activity, assaults on older people, and unleashed dogs. Those in moderate-income neighborhoods were less likely to have experienced crime or problems with dogs, he said.

LOS ANGELES — Fears about personal safety appear to be a barrier to exercise among older African Americans in low- and moderate-income areas of Los Angeles, Dr. O. Kenrik Duru reported at the annual meeting of the Society of General Internal Medicine.

While developing a community-based physical activity intervention for older African Americans, the investigators conducted six focus groups in Los Angeles during 2004 and 2005 with a total of 59 African Americans aged 60 years and older. The subjects were from four senior centers that had significant African American populations—two in a low-income area and two in moderate-income areas. In each center, investigators recruited a convenience sample of interested ambulatory seniors.

The participants averaged 66 years old and 75% were female; 59% had graduated from high school, and 71% had annual incomes of less than $10,000, said Dr. Duru, a third-year National Research Service Award fellow at the University of California, Los Angeles.

Many participants reported exercising three to seven times weekly, but often the duration was short (10–15 minutes). Residents of both low- and moderate-income neighborhoods preferred indoor activity, such as low-impact aerobics, to outdoor activity. Although participants consistently mentioned a concern for physical safety, other reasons for preferring the indoors included availability of air conditioning and restrooms, and the avoidance of bugs.

Participants in low-income neighborhoods worried most about things they had seen in their neighborhoods, such as gang activity, assaults on older people, and unleashed dogs. Those in moderate-income neighborhoods were less likely to have experienced crime or problems with dogs, he said.

LOS ANGELES — Fears about personal safety appear to be a barrier to exercise among older African Americans in low- and moderate-income areas of Los Angeles, Dr. O. Kenrik Duru reported at the annual meeting of the Society of General Internal Medicine.

While developing a community-based physical activity intervention for older African Americans, the investigators conducted six focus groups in Los Angeles during 2004 and 2005 with a total of 59 African Americans aged 60 years and older. The subjects were from four senior centers that had significant African American populations—two in a low-income area and two in moderate-income areas. In each center, investigators recruited a convenience sample of interested ambulatory seniors.

The participants averaged 66 years old and 75% were female; 59% had graduated from high school, and 71% had annual incomes of less than $10,000, said Dr. Duru, a third-year National Research Service Award fellow at the University of California, Los Angeles.

Many participants reported exercising three to seven times weekly, but often the duration was short (10–15 minutes). Residents of both low- and moderate-income neighborhoods preferred indoor activity, such as low-impact aerobics, to outdoor activity. Although participants consistently mentioned a concern for physical safety, other reasons for preferring the indoors included availability of air conditioning and restrooms, and the avoidance of bugs.

Participants in low-income neighborhoods worried most about things they had seen in their neighborhoods, such as gang activity, assaults on older people, and unleashed dogs. Those in moderate-income neighborhoods were less likely to have experienced crime or problems with dogs, he said.

LOS ANGELES — Physicians and patients are less likely to favor bisphosphonate therapy for osteoporosis when efficacy is expressed in terms of absolute risk reduction, as health literacy experts recommend, rather than relative risk reduction, Dr. Christine A. Sinsky reported at the annual meeting of the Society of General Internal Medicine.

Despite the widespread use of relative risk reduction (RRR) values to describe the benefits of osteoporosis therapy, health literacy experts favor focusing on absolute risk reduction (ARR). That's because RRR tends to overstate risk reduction when there is a low baseline frequency of a condition, such as hip fracture in osteoporosis, said Dr. Sinsky, an internist in private practice in Dubuque, Iowa.

Data cited by the U.S. Preventive Services Task Force (USPSTF) suggest that after 5 years of treatment with bisphosphonates, the RRR for hip fracture is 35%, while the absolute risk of fracture in the at-risk population decreases from 3% to 2%, yielding a 1% ARR (Ann. Int. Med. 2002;137:526–8).

Investigators administered a 10-item questionnaire to 641 consecutive female patients (aged 50 years or older) and all general medicine physicians at a university-based practice and a community practice. The patients were asked: “You have a bone density test that indicates osteoporosis. You have full drug coverage. Are you interested in treatment?” The physicians were asked: “Your 65-year-old patient has a [dual-energy x-ray absorptiometry] scan that indicates osteoporosis. The patient has full drug coverage. Would you recommend treatment?” Other scenarios presented out-of-pocket costs to the patient ranging from 0% to 90%. Subsequent questions presented similar scenarios but with efficacy of treatment presented as either RRR or ARR.

When treatment benefit was presented as RRR, 86% of patients expressed interest, which was significantly higher than the 57% rate when benefit was expressed as ARR. Similarly, physicians were significantly more likely to recommend osteoporosis treatment for their patients when treatment benefits were presented as RRR (97%) as opposed to ARR (53%). One limitation of the study is that patients may not have understood the clinical consequences of hip fractures, Dr. Sinsky noted.

LOS ANGELES — Physicians and patients are less likely to favor bisphosphonate therapy for osteoporosis when efficacy is expressed in terms of absolute risk reduction, as health literacy experts recommend, rather than relative risk reduction, Dr. Christine A. Sinsky reported at the annual meeting of the Society of General Internal Medicine.

Despite the widespread use of relative risk reduction (RRR) values to describe the benefits of osteoporosis therapy, health literacy experts favor focusing on absolute risk reduction (ARR). That's because RRR tends to overstate risk reduction when there is a low baseline frequency of a condition, such as hip fracture in osteoporosis, said Dr. Sinsky, an internist in private practice in Dubuque, Iowa.

Data cited by the U.S. Preventive Services Task Force (USPSTF) suggest that after 5 years of treatment with bisphosphonates, the RRR for hip fracture is 35%, while the absolute risk of fracture in the at-risk population decreases from 3% to 2%, yielding a 1% ARR (Ann. Int. Med. 2002;137:526–8).

Investigators administered a 10-item questionnaire to 641 consecutive female patients (aged 50 years or older) and all general medicine physicians at a university-based practice and a community practice. The patients were asked: “You have a bone density test that indicates osteoporosis. You have full drug coverage. Are you interested in treatment?” The physicians were asked: “Your 65-year-old patient has a [dual-energy x-ray absorptiometry] scan that indicates osteoporosis. The patient has full drug coverage. Would you recommend treatment?” Other scenarios presented out-of-pocket costs to the patient ranging from 0% to 90%. Subsequent questions presented similar scenarios but with efficacy of treatment presented as either RRR or ARR.

When treatment benefit was presented as RRR, 86% of patients expressed interest, which was significantly higher than the 57% rate when benefit was expressed as ARR. Similarly, physicians were significantly more likely to recommend osteoporosis treatment for their patients when treatment benefits were presented as RRR (97%) as opposed to ARR (53%). One limitation of the study is that patients may not have understood the clinical consequences of hip fractures, Dr. Sinsky noted.

LOS ANGELES — Physicians and patients are less likely to favor bisphosphonate therapy for osteoporosis when efficacy is expressed in terms of absolute risk reduction, as health literacy experts recommend, rather than relative risk reduction, Dr. Christine A. Sinsky reported at the annual meeting of the Society of General Internal Medicine.

Despite the widespread use of relative risk reduction (RRR) values to describe the benefits of osteoporosis therapy, health literacy experts favor focusing on absolute risk reduction (ARR). That's because RRR tends to overstate risk reduction when there is a low baseline frequency of a condition, such as hip fracture in osteoporosis, said Dr. Sinsky, an internist in private practice in Dubuque, Iowa.

Data cited by the U.S. Preventive Services Task Force (USPSTF) suggest that after 5 years of treatment with bisphosphonates, the RRR for hip fracture is 35%, while the absolute risk of fracture in the at-risk population decreases from 3% to 2%, yielding a 1% ARR (Ann. Int. Med. 2002;137:526–8).

Investigators administered a 10-item questionnaire to 641 consecutive female patients (aged 50 years or older) and all general medicine physicians at a university-based practice and a community practice. The patients were asked: “You have a bone density test that indicates osteoporosis. You have full drug coverage. Are you interested in treatment?” The physicians were asked: “Your 65-year-old patient has a [dual-energy x-ray absorptiometry] scan that indicates osteoporosis. The patient has full drug coverage. Would you recommend treatment?” Other scenarios presented out-of-pocket costs to the patient ranging from 0% to 90%. Subsequent questions presented similar scenarios but with efficacy of treatment presented as either RRR or ARR.

When treatment benefit was presented as RRR, 86% of patients expressed interest, which was significantly higher than the 57% rate when benefit was expressed as ARR. Similarly, physicians were significantly more likely to recommend osteoporosis treatment for their patients when treatment benefits were presented as RRR (97%) as opposed to ARR (53%). One limitation of the study is that patients may not have understood the clinical consequences of hip fractures, Dr. Sinsky noted.

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Oregon, total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The goal of her study was to determine if these different end-of-life practice patterns could be explained by patient preferences. The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 (65%) completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live because of a serious illness. Given this scenario, participants responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% of the respondents were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato. “There seems to be a correlation between wanting MV and believing that it is effective in returning you to normal activity. I think it's hard for patients to conceptualize what these things mean unless they have a family member who has been in the ICU,” she said.

The spending calculations were done with standardized prices—the End-of-Life Expenditure Index—in each U.S. hospital referral region, and the analyses were adjusted for age, gender, and race.

The original hypothesis, that individual preferences drive the regional variations in end-of-life spending, was not borne out by the data.

In general, participants' concerns about and preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major limitation of this study was the 35% nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all of Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most of the participants said they would prefer treatment that would ease pain rather than extend life.

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Oregon, total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The goal of her study was to determine if these different end-of-life practice patterns could be explained by patient preferences. The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 (65%) completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live because of a serious illness. Given this scenario, participants responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% of the respondents were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato. “There seems to be a correlation between wanting MV and believing that it is effective in returning you to normal activity. I think it's hard for patients to conceptualize what these things mean unless they have a family member who has been in the ICU,” she said.

The spending calculations were done with standardized prices—the End-of-Life Expenditure Index—in each U.S. hospital referral region, and the analyses were adjusted for age, gender, and race.

The original hypothesis, that individual preferences drive the regional variations in end-of-life spending, was not borne out by the data.

In general, participants' concerns about and preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major limitation of this study was the 35% nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all of Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most of the participants said they would prefer treatment that would ease pain rather than extend life.

LOS ANGELES — End-of-life spending for Medicare beneficiaries varies widely based on geographic location, but individual patient preferences do not drive these regional variations, Dr. Amber E. Barnato reported at the annual meeting of the Society of General Internal Medicine.

For example, average per capita costs in the last 6 months of life among beneficiaries in Portland, Oregon, total $9,600, compared with $2,400 in Los Angeles, said Dr. Barnato, of the University of Pittsburgh.

A previous national survey with structured vignettes asking about patient preferences for treatment found that doctors in high-intensity regions are more likely to recommend tests and refer to specialists, and are less likely to recommend hospice care (Ann. Intern. Med. 2003;138:288–98).

The goal of her study was to determine if these different end-of-life practice patterns could be explained by patient preferences. The investigators surveyed a national probability sample of fee-for-service Medicare beneficiaries aged 65 years or older. Potential subjects were identified from the Medicare beneficiaries database for the entire United States; a sample of 3,845 people were asked to participate in the study, and 2,515 (65%) completed the survey.

The researchers asked respondents to imagine that they had less than 1 year to live because of a serious illness. Given this scenario, participants responded to questions about their preferences for active treatment, ventilator use, and palliative care.

The mean age of respondents was 75.6 years, 42% of the respondents were male, and 82% were non-Hispanic white, 7% black, and 5% Hispanic.

Overall, 44% of participants said they worried about getting too little treatment in the last year of their lives, whereas 49% worried about getting too much treatment. A total of 16% would prefer potentially life-prolonging drugs that made them feel worse all the time, while 75% would prefer palliative drugs, even if they might shorten life.

Thirteen percent of respondents would prefer mechanical ventilation if it would extend their life by 1 week, and 22% would prefer MV if it would extend life by 1 month. A large proportion of respondents thought the likelihood of returning to normal activity after being on a ventilator was high, according to Dr. Barnato. “There seems to be a correlation between wanting MV and believing that it is effective in returning you to normal activity. I think it's hard for patients to conceptualize what these things mean unless they have a family member who has been in the ICU,” she said.

The spending calculations were done with standardized prices—the End-of-Life Expenditure Index—in each U.S. hospital referral region, and the analyses were adjusted for age, gender, and race.

The original hypothesis, that individual preferences drive the regional variations in end-of-life spending, was not borne out by the data.

In general, participants' concerns about and preferences for end-of-life treatment were not significantly different among quintiles of the End-of-Life Expenditure Index, although in higher-intensity regions respondents were less likely to want palliative drugs that might shorten life. This exception no longer held, however, once multivariable analyses were adjusted for sociodemographic variables and health status.

A major limitation of this study was the 35% nonresponse rate. It is possible that the original hypothesis was not borne out because patterns of nonresponse differed by region.

The survey showed that almost all of Medicare enrollees worry that the amount of treatment they want in their last year of life will not align with what they will actually receive. When asked to choose, most of the participants said they would prefer treatment that would ease pain rather than extend life.

LOS ANGELES — Referral of patients with adenomas 6–9 mm in diameter for optical colonoscopy remains an area of contention, Dr. David A. Lieberman said at the annual Digestive Disease Week.

Computed tomography colonoscopy (CTC) may miss 40% of lesions of that size, and 7%–20% of the lesions will be at an advanced stage when eventually identified with optical colonoscopy (OC), said Dr. Lieberman, chief of gastroenterology at the Veterans Affairs Medical Center in Portland, Ore.

CTC and OC have comparable rates of identification of adenomas larger than 9 mm in diameter. Using CTC in tandem with OC, some investigators have shown that CTC can identify adenomas measuring 6–9 mm with a sensitivity of 94% and specificity of 96%. Other researchers using CTC, however, have found similar sensitivities, but specificities in the 55%–60% range. The differences may be accounted for by interobserver variability and the difficulty of detecting flat adenomas.

Dr. Lieberman reviewed the natural history of adenomas, 70% of which are tubular and less than 1 cm in diameter when found at screening. There is some epidemiologic evidence that patients with one or two tubular adenomas have a lower risk of progressing to cancer than patients with more adenomas. Polyps less than 9 mm in diameter that are left in place remain stable in 25% of cases, regress in 35% of cases, but progress in 40% of cases, particularly if they are smaller than 5 mm. Polyps 3–9 mm in diameter grow approximately 0.58 mm/year, and the average polyp grows from 6.4 mm to 7.3 mm within 2 years (Am. J. Gastroenterol. 1997;92:1117–20).

Little is known of the natural history of diminutive polyps (those less than 5 mm in diameter), and the availability of CTC offers researchers a chance to study them. On the basis of recent research, diminutive polyps will develop high-grade dysplasia in up to 2.3% of cases and become cancerous in up to 1.5% of cases. Given this prevalence, Dr. Lieberman asked meeting attendees to consider whether it is justifiable to ignore diminutive polyps and to defer colonoscopy when patients are known to have 6- to 9-mm polyps.

Because the risk of conversion into high-grade dysplasia is directly associated with polyp size, many physicians and patients demand colonoscopy for polyps larger than 5 mm in diameter. The clinician's dilemma is whether to suggest immediate OC to patients with diminutive polyps or to repeat CTC—and, if the latter, at what interval. Cost issues for clinicians providing CTC on demand include establishing a threshold for what constitutes a positive test, who gets referred for OC, and how to handle the expense of evaluating extracolonic findings.

If a large proportion of CTC-evaluated patients get referrals to optical colonoscopy, CTC will not be cost-effective. “We in the GI community are going to have to wrestle with the issue of who gets colonoscopy,” Dr. Lieberman told meeting attendees.

The management of diminutive polyps is controversial because the risk of advanced neoplasia is low, and the guidelines developed by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society recommend ignoring diminutive polyps. However, “the strategy of not reporting adenomas smaller than 6 mm may lead to medicolegal problems,” Dr. Lieberman said.

LOS ANGELES — Referral of patients with adenomas 6–9 mm in diameter for optical colonoscopy remains an area of contention, Dr. David A. Lieberman said at the annual Digestive Disease Week.

Computed tomography colonoscopy (CTC) may miss 40% of lesions of that size, and 7%–20% of the lesions will be at an advanced stage when eventually identified with optical colonoscopy (OC), said Dr. Lieberman, chief of gastroenterology at the Veterans Affairs Medical Center in Portland, Ore.

CTC and OC have comparable rates of identification of adenomas larger than 9 mm in diameter. Using CTC in tandem with OC, some investigators have shown that CTC can identify adenomas measuring 6–9 mm with a sensitivity of 94% and specificity of 96%. Other researchers using CTC, however, have found similar sensitivities, but specificities in the 55%–60% range. The differences may be accounted for by interobserver variability and the difficulty of detecting flat adenomas.

Dr. Lieberman reviewed the natural history of adenomas, 70% of which are tubular and less than 1 cm in diameter when found at screening. There is some epidemiologic evidence that patients with one or two tubular adenomas have a lower risk of progressing to cancer than patients with more adenomas. Polyps less than 9 mm in diameter that are left in place remain stable in 25% of cases, regress in 35% of cases, but progress in 40% of cases, particularly if they are smaller than 5 mm. Polyps 3–9 mm in diameter grow approximately 0.58 mm/year, and the average polyp grows from 6.4 mm to 7.3 mm within 2 years (Am. J. Gastroenterol. 1997;92:1117–20).

Little is known of the natural history of diminutive polyps (those less than 5 mm in diameter), and the availability of CTC offers researchers a chance to study them. On the basis of recent research, diminutive polyps will develop high-grade dysplasia in up to 2.3% of cases and become cancerous in up to 1.5% of cases. Given this prevalence, Dr. Lieberman asked meeting attendees to consider whether it is justifiable to ignore diminutive polyps and to defer colonoscopy when patients are known to have 6- to 9-mm polyps.

Because the risk of conversion into high-grade dysplasia is directly associated with polyp size, many physicians and patients demand colonoscopy for polyps larger than 5 mm in diameter. The clinician's dilemma is whether to suggest immediate OC to patients with diminutive polyps or to repeat CTC—and, if the latter, at what interval. Cost issues for clinicians providing CTC on demand include establishing a threshold for what constitutes a positive test, who gets referred for OC, and how to handle the expense of evaluating extracolonic findings.

If a large proportion of CTC-evaluated patients get referrals to optical colonoscopy, CTC will not be cost-effective. “We in the GI community are going to have to wrestle with the issue of who gets colonoscopy,” Dr. Lieberman told meeting attendees.

The management of diminutive polyps is controversial because the risk of advanced neoplasia is low, and the guidelines developed by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society recommend ignoring diminutive polyps. However, “the strategy of not reporting adenomas smaller than 6 mm may lead to medicolegal problems,” Dr. Lieberman said.

LOS ANGELES — Referral of patients with adenomas 6–9 mm in diameter for optical colonoscopy remains an area of contention, Dr. David A. Lieberman said at the annual Digestive Disease Week.

Computed tomography colonoscopy (CTC) may miss 40% of lesions of that size, and 7%–20% of the lesions will be at an advanced stage when eventually identified with optical colonoscopy (OC), said Dr. Lieberman, chief of gastroenterology at the Veterans Affairs Medical Center in Portland, Ore.

CTC and OC have comparable rates of identification of adenomas larger than 9 mm in diameter. Using CTC in tandem with OC, some investigators have shown that CTC can identify adenomas measuring 6–9 mm with a sensitivity of 94% and specificity of 96%. Other researchers using CTC, however, have found similar sensitivities, but specificities in the 55%–60% range. The differences may be accounted for by interobserver variability and the difficulty of detecting flat adenomas.

Dr. Lieberman reviewed the natural history of adenomas, 70% of which are tubular and less than 1 cm in diameter when found at screening. There is some epidemiologic evidence that patients with one or two tubular adenomas have a lower risk of progressing to cancer than patients with more adenomas. Polyps less than 9 mm in diameter that are left in place remain stable in 25% of cases, regress in 35% of cases, but progress in 40% of cases, particularly if they are smaller than 5 mm. Polyps 3–9 mm in diameter grow approximately 0.58 mm/year, and the average polyp grows from 6.4 mm to 7.3 mm within 2 years (Am. J. Gastroenterol. 1997;92:1117–20).

Little is known of the natural history of diminutive polyps (those less than 5 mm in diameter), and the availability of CTC offers researchers a chance to study them. On the basis of recent research, diminutive polyps will develop high-grade dysplasia in up to 2.3% of cases and become cancerous in up to 1.5% of cases. Given this prevalence, Dr. Lieberman asked meeting attendees to consider whether it is justifiable to ignore diminutive polyps and to defer colonoscopy when patients are known to have 6- to 9-mm polyps.

Because the risk of conversion into high-grade dysplasia is directly associated with polyp size, many physicians and patients demand colonoscopy for polyps larger than 5 mm in diameter. The clinician's dilemma is whether to suggest immediate OC to patients with diminutive polyps or to repeat CTC—and, if the latter, at what interval. Cost issues for clinicians providing CTC on demand include establishing a threshold for what constitutes a positive test, who gets referred for OC, and how to handle the expense of evaluating extracolonic findings.

If a large proportion of CTC-evaluated patients get referrals to optical colonoscopy, CTC will not be cost-effective. “We in the GI community are going to have to wrestle with the issue of who gets colonoscopy,” Dr. Lieberman told meeting attendees.

The management of diminutive polyps is controversial because the risk of advanced neoplasia is low, and the guidelines developed by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society recommend ignoring diminutive polyps. However, “the strategy of not reporting adenomas smaller than 6 mm may lead to medicolegal problems,” Dr. Lieberman said.

LOS ANGELES — New methods and devices for diagnostic colonoscopy improve the physician's ability to image the entire colon and to identify so-called hidden polyps, which are often missed by current techniques, Dr. Jacques Van Dam said at the annual Digestive Disease Week.

With these new techniques, patients may be more willing to be screened as well, said Dr. Van Dam of Stanford (Calif.) University. He reviewed six studies with 465 patients who underwent two colonoscopies on the same day. The results showed that physicians missed 2.1% of polyps 10 mm in diameter or larger, 13% of polyps measuring 5–10 mm, and 26% of adenomas less than 5 mm in diameter (Am. J. Gastroenterol. 2006;101:343–50).

Colorectal cancer screening has become increasingly important in gastroenterology. In a 2005 study, 5%–20% of all colonoscopies failed to reach the cecum (Endoscopy 2005;38:209–13). Current colonoscopic devices are prone to looping on insertion, leading to incomplete procedures and the need for sedation and analgesia. These devices require force against the colon wall to advance them to the cecum. Physicians using the devices require rigorous training.

Several investigational colonoscopy devices may increase the rate of successful colonoscopies and lessen patient discomfort, he said.

The CathCam is a disposable multilumen, wire-guided catheter. An outer segment 11 mm in diameter contains a 3-mm-diameter camera with six light-emitting diodes. The guide wire is placed via colonoscopy. In 14 volunteers with a current or previous failure of complete colonoscopy, 12 procedures reached the cecum, one was blocked by a stricture, and one patient dropped out. All patients were sedated with 2–5 mg of midazolam. The average time to reach the cecum was 24 minutes. In nine cases, the new device helped to identify important findings that had been missed with previously failed colonoscopies (Endoscopy 2005;38:209–13).

The Aer-O-Scope, a self-propelling, self-navigating disposable device, allows successful imaging of the colon independent of the clinician's skill. In a test that included standard colonoscopy, the device reached the cecum in 10 of 12 healthy volunteers, in a mean time of about 14 minutes (Gastroenterology 2006;130: 672–7).

A computer-assisted colonoscope made by NeoGuide Systems is propelled with the aid of a follow-the-leader algorithm, eliminating the force applied in standard colonoscopies. A prospective, nonrandomized, unblinded feasibility study was done with five physicians of various levels of experience. In all 10 consecutive patients (6 men and 4 women, age range 19–80) in the study, the device reached the cecum and enabled identification of diverticular disease in two cases and multiple colonic polyps in two cases. Polyps were removed using standard endoscopic techniques.

The Third Eye Retroscope (Avantis Medical Systems) is a disposable device used in conjunction with colonoscopy. When tested using tandem colonoscopy on latex models configured with polyps located on both sides of folds, the Third Eye identified 12% of distal side and 81% of proximal side polyps.

The PillCam Colon, a new design of the PillCam capsule that is not yet approved for U.S. use, measures 11 mm by 32 mm. The device, which is swallowed, requires no sedation or intubation. A specially developed procedure combines laxatives and prokinetic agents. The Given Diagnostic Imaging System is used for image acquisition, processing, and interpretation.

Dr. Van Dam revealed that he receives research support from, is a consultant to, and owns stock in NeoGuide Systems Inc. and Avantis Medical Systems Inc.

LOS ANGELES — New methods and devices for diagnostic colonoscopy improve the physician's ability to image the entire colon and to identify so-called hidden polyps, which are often missed by current techniques, Dr. Jacques Van Dam said at the annual Digestive Disease Week.

With these new techniques, patients may be more willing to be screened as well, said Dr. Van Dam of Stanford (Calif.) University. He reviewed six studies with 465 patients who underwent two colonoscopies on the same day. The results showed that physicians missed 2.1% of polyps 10 mm in diameter or larger, 13% of polyps measuring 5–10 mm, and 26% of adenomas less than 5 mm in diameter (Am. J. Gastroenterol. 2006;101:343–50).

Colorectal cancer screening has become increasingly important in gastroenterology. In a 2005 study, 5%–20% of all colonoscopies failed to reach the cecum (Endoscopy 2005;38:209–13). Current colonoscopic devices are prone to looping on insertion, leading to incomplete procedures and the need for sedation and analgesia. These devices require force against the colon wall to advance them to the cecum. Physicians using the devices require rigorous training.

Several investigational colonoscopy devices may increase the rate of successful colonoscopies and lessen patient discomfort, he said.

The CathCam is a disposable multilumen, wire-guided catheter. An outer segment 11 mm in diameter contains a 3-mm-diameter camera with six light-emitting diodes. The guide wire is placed via colonoscopy. In 14 volunteers with a current or previous failure of complete colonoscopy, 12 procedures reached the cecum, one was blocked by a stricture, and one patient dropped out. All patients were sedated with 2–5 mg of midazolam. The average time to reach the cecum was 24 minutes. In nine cases, the new device helped to identify important findings that had been missed with previously failed colonoscopies (Endoscopy 2005;38:209–13).

The Aer-O-Scope, a self-propelling, self-navigating disposable device, allows successful imaging of the colon independent of the clinician's skill. In a test that included standard colonoscopy, the device reached the cecum in 10 of 12 healthy volunteers, in a mean time of about 14 minutes (Gastroenterology 2006;130: 672–7).

A computer-assisted colonoscope made by NeoGuide Systems is propelled with the aid of a follow-the-leader algorithm, eliminating the force applied in standard colonoscopies. A prospective, nonrandomized, unblinded feasibility study was done with five physicians of various levels of experience. In all 10 consecutive patients (6 men and 4 women, age range 19–80) in the study, the device reached the cecum and enabled identification of diverticular disease in two cases and multiple colonic polyps in two cases. Polyps were removed using standard endoscopic techniques.

The Third Eye Retroscope (Avantis Medical Systems) is a disposable device used in conjunction with colonoscopy. When tested using tandem colonoscopy on latex models configured with polyps located on both sides of folds, the Third Eye identified 12% of distal side and 81% of proximal side polyps.

The PillCam Colon, a new design of the PillCam capsule that is not yet approved for U.S. use, measures 11 mm by 32 mm. The device, which is swallowed, requires no sedation or intubation. A specially developed procedure combines laxatives and prokinetic agents. The Given Diagnostic Imaging System is used for image acquisition, processing, and interpretation.

Dr. Van Dam revealed that he receives research support from, is a consultant to, and owns stock in NeoGuide Systems Inc. and Avantis Medical Systems Inc.

LOS ANGELES — New methods and devices for diagnostic colonoscopy improve the physician's ability to image the entire colon and to identify so-called hidden polyps, which are often missed by current techniques, Dr. Jacques Van Dam said at the annual Digestive Disease Week.

With these new techniques, patients may be more willing to be screened as well, said Dr. Van Dam of Stanford (Calif.) University. He reviewed six studies with 465 patients who underwent two colonoscopies on the same day. The results showed that physicians missed 2.1% of polyps 10 mm in diameter or larger, 13% of polyps measuring 5–10 mm, and 26% of adenomas less than 5 mm in diameter (Am. J. Gastroenterol. 2006;101:343–50).

Colorectal cancer screening has become increasingly important in gastroenterology. In a 2005 study, 5%–20% of all colonoscopies failed to reach the cecum (Endoscopy 2005;38:209–13). Current colonoscopic devices are prone to looping on insertion, leading to incomplete procedures and the need for sedation and analgesia. These devices require force against the colon wall to advance them to the cecum. Physicians using the devices require rigorous training.

Several investigational colonoscopy devices may increase the rate of successful colonoscopies and lessen patient discomfort, he said.

The CathCam is a disposable multilumen, wire-guided catheter. An outer segment 11 mm in diameter contains a 3-mm-diameter camera with six light-emitting diodes. The guide wire is placed via colonoscopy. In 14 volunteers with a current or previous failure of complete colonoscopy, 12 procedures reached the cecum, one was blocked by a stricture, and one patient dropped out. All patients were sedated with 2–5 mg of midazolam. The average time to reach the cecum was 24 minutes. In nine cases, the new device helped to identify important findings that had been missed with previously failed colonoscopies (Endoscopy 2005;38:209–13).

The Aer-O-Scope, a self-propelling, self-navigating disposable device, allows successful imaging of the colon independent of the clinician's skill. In a test that included standard colonoscopy, the device reached the cecum in 10 of 12 healthy volunteers, in a mean time of about 14 minutes (Gastroenterology 2006;130: 672–7).

A computer-assisted colonoscope made by NeoGuide Systems is propelled with the aid of a follow-the-leader algorithm, eliminating the force applied in standard colonoscopies. A prospective, nonrandomized, unblinded feasibility study was done with five physicians of various levels of experience. In all 10 consecutive patients (6 men and 4 women, age range 19–80) in the study, the device reached the cecum and enabled identification of diverticular disease in two cases and multiple colonic polyps in two cases. Polyps were removed using standard endoscopic techniques.

The Third Eye Retroscope (Avantis Medical Systems) is a disposable device used in conjunction with colonoscopy. When tested using tandem colonoscopy on latex models configured with polyps located on both sides of folds, the Third Eye identified 12% of distal side and 81% of proximal side polyps.

The PillCam Colon, a new design of the PillCam capsule that is not yet approved for U.S. use, measures 11 mm by 32 mm. The device, which is swallowed, requires no sedation or intubation. A specially developed procedure combines laxatives and prokinetic agents. The Given Diagnostic Imaging System is used for image acquisition, processing, and interpretation.

Dr. Van Dam revealed that he receives research support from, is a consultant to, and owns stock in NeoGuide Systems Inc. and Avantis Medical Systems Inc.

LOS ANGELES —Women with type 2 diabetes may be treated for dyslipidemia less aggressively than men, and therefore may be at higher risk of developing cardiovascular disease, Dr. Quyen Ngo-Metzger reported at the annual meeting of the Society of General Internal Medicine.

Coronary heart disease is a leading cause of death among women and among all patients with type 2 diabetes. Diabetes confers a four times greater risk of coronary heart disease in women, compared with a doubling of risk in men, said Dr. Ngo-Metzger, an assistant professor of medicine at the University of California, Irvine.

Dr. Ngo-Metzger and her associates examined quality of care in a sample of 4,879 men and 7,654 women with type 2 diabetes (mean age 56 years) who were treated at 16 Kaiser Permanente Georgia practices in 2002.

About two-thirds of men and women received recommended hemoglobin A_1c and cholesterol testing. About one-quarter of men (25%) and women (27%) achieved glycemic control (a hemoglobin A_1c value of less than 7%).

Overall, 72% of men and 68% of women achieved LDL-cholesterol levels of less than 130 mg/dL; this difference was deemed statistically significant.

After adjustment of the data for age and comorbid conditions in multivariate analyses, men were 26% more likely than women to have an LDL-cholesterol value of less than 130 mg/dL.

Among high-risk patients with known coronary heart disease, 86% of men and 76% of women had an LDL-cholesterol level of less than 130 mg/dL; after adjustment for age and comorbidity, men were twice as likely as women to have lipid control at this cutoff.

In addition, 56% of men and 44% of women had an LDL-cholesterol concentration of less than 100 mg/dL; after adjustment, men were 64% more likely than women to have achieved control using this more stringent definition, she reported.

Overall, 43% of men were prescribed statins, compared with 37% of women; this difference was found to be statistically significant, Dr. Ngo-Metzger said.

It is unlikely that the gender disparities were due to lack of access to care, more comorbidities in women, gender differences in choosing to have cholesterol measured, or lower compliance with statins among women, she added.

“Clinicians need to be reminded of high coronary heart disease mortality among women with diabetes. Diabetic women with high cholesterol need to have their dyslipidemia treated aggressively,” Dr. Ngo-Metzger said.

Further research is needed, she noted, to determine whether the differences reflect providers' prescribing habits or personal preferences among women and men.

LOS ANGELES —Women with type 2 diabetes may be treated for dyslipidemia less aggressively than men, and therefore may be at higher risk of developing cardiovascular disease, Dr. Quyen Ngo-Metzger reported at the annual meeting of the Society of General Internal Medicine.

Coronary heart disease is a leading cause of death among women and among all patients with type 2 diabetes. Diabetes confers a four times greater risk of coronary heart disease in women, compared with a doubling of risk in men, said Dr. Ngo-Metzger, an assistant professor of medicine at the University of California, Irvine.

Dr. Ngo-Metzger and her associates examined quality of care in a sample of 4,879 men and 7,654 women with type 2 diabetes (mean age 56 years) who were treated at 16 Kaiser Permanente Georgia practices in 2002.

About two-thirds of men and women received recommended hemoglobin A_1c and cholesterol testing. About one-quarter of men (25%) and women (27%) achieved glycemic control (a hemoglobin A_1c value of less than 7%).

Overall, 72% of men and 68% of women achieved LDL-cholesterol levels of less than 130 mg/dL; this difference was deemed statistically significant.

After adjustment of the data for age and comorbid conditions in multivariate analyses, men were 26% more likely than women to have an LDL-cholesterol value of less than 130 mg/dL.

Among high-risk patients with known coronary heart disease, 86% of men and 76% of women had an LDL-cholesterol level of less than 130 mg/dL; after adjustment for age and comorbidity, men were twice as likely as women to have lipid control at this cutoff.

In addition, 56% of men and 44% of women had an LDL-cholesterol concentration of less than 100 mg/dL; after adjustment, men were 64% more likely than women to have achieved control using this more stringent definition, she reported.

Overall, 43% of men were prescribed statins, compared with 37% of women; this difference was found to be statistically significant, Dr. Ngo-Metzger said.

It is unlikely that the gender disparities were due to lack of access to care, more comorbidities in women, gender differences in choosing to have cholesterol measured, or lower compliance with statins among women, she added.

“Clinicians need to be reminded of high coronary heart disease mortality among women with diabetes. Diabetic women with high cholesterol need to have their dyslipidemia treated aggressively,” Dr. Ngo-Metzger said.

Further research is needed, she noted, to determine whether the differences reflect providers' prescribing habits or personal preferences among women and men.

LOS ANGELES —Women with type 2 diabetes may be treated for dyslipidemia less aggressively than men, and therefore may be at higher risk of developing cardiovascular disease, Dr. Quyen Ngo-Metzger reported at the annual meeting of the Society of General Internal Medicine.

Coronary heart disease is a leading cause of death among women and among all patients with type 2 diabetes. Diabetes confers a four times greater risk of coronary heart disease in women, compared with a doubling of risk in men, said Dr. Ngo-Metzger, an assistant professor of medicine at the University of California, Irvine.

Dr. Ngo-Metzger and her associates examined quality of care in a sample of 4,879 men and 7,654 women with type 2 diabetes (mean age 56 years) who were treated at 16 Kaiser Permanente Georgia practices in 2002.

About two-thirds of men and women received recommended hemoglobin A_1c and cholesterol testing. About one-quarter of men (25%) and women (27%) achieved glycemic control (a hemoglobin A_1c value of less than 7%).

Overall, 72% of men and 68% of women achieved LDL-cholesterol levels of less than 130 mg/dL; this difference was deemed statistically significant.

After adjustment of the data for age and comorbid conditions in multivariate analyses, men were 26% more likely than women to have an LDL-cholesterol value of less than 130 mg/dL.

Among high-risk patients with known coronary heart disease, 86% of men and 76% of women had an LDL-cholesterol level of less than 130 mg/dL; after adjustment for age and comorbidity, men were twice as likely as women to have lipid control at this cutoff.

In addition, 56% of men and 44% of women had an LDL-cholesterol concentration of less than 100 mg/dL; after adjustment, men were 64% more likely than women to have achieved control using this more stringent definition, she reported.

Overall, 43% of men were prescribed statins, compared with 37% of women; this difference was found to be statistically significant, Dr. Ngo-Metzger said.

It is unlikely that the gender disparities were due to lack of access to care, more comorbidities in women, gender differences in choosing to have cholesterol measured, or lower compliance with statins among women, she added.

“Clinicians need to be reminded of high coronary heart disease mortality among women with diabetes. Diabetic women with high cholesterol need to have their dyslipidemia treated aggressively,” Dr. Ngo-Metzger said.

Further research is needed, she noted, to determine whether the differences reflect providers' prescribing habits or personal preferences among women and men.

LOS ANGELES — A prediction rule combining five easily obtainable risk factors distinguishes with high sensitivity women at high risk of developing osteoporotic fractures within the next 3 years, Dr. Idris Guessous reported at the annual meeting of the Society of General Internal Medicine.

The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk (SEMOF) study was a 3-year, prospective, multicenter study (n = 623) that computed a prediction score using low heel ultrasound stiffness index (SI), older age, fracture history, recent fall, and missed chair test to predict osteoporotic hip fractures and other nonvertebral fractures.

The objective of the study was to compute a prediction rule that would identify women at high risk of osteoporotic fracture in general, or a hip fracture in particular, within the next 3 years, said Dr. Guessous of the University Hospital of Lausanne, Switzerland.

The heel bone ultrasonometer (Lunar Corp., Madison, Wisc.) was chosen because it is simple, inexpensive, noninvasive, and transportable. Of 7,114 Swiss women who responded to a mailed request to participate, 6,174 women between 70 and 85 years old were enrolled. Exclusion criteria included previous hip fracture, bilateral hip replacement, renal failure, and active cancer.

Bone SI was calculated using quantitative ultrasound of the heel, broadband ultrasound attenuation, and speed of sound as the inputs. SI is expressed as a percentage of values obtained by the manufacturer in a young adult population. Osteoporotic fractures were defined as hip, wrist, or arm breaks that occurred spontaneously or secondary to falling from standing height or lower despite a low level of trauma.

The investigators included baseline characteristics (age, weight, height, body mass index), known risk factors for osteoporosis (fracture history, history of maternal hip fracture, current smoking habits, early menopause, surgical menopause), fall (history of recent fall, missed chair test), and SI as parameters to develop a prediction score. The investigators then used bootstrap methods to evaluate the stability of the score, Dr. Guessous said.

Mean follow-up was 2.8 years (17,546 person-years). Five risk factors were independent, significant predictors of the incidence of osteoporotic fractures: age older than 75, SI greater than 78%, history of any prior fracture, history of a fall during the last 12 months, and missed chair test (not being able to rise from a chair three successive times without using one's arms).

The investigators assigned a score to each of the five significant predictors: age, up to 3; SI, up to 7.5; history of fall within past 12 months, 1.5; fracture history, 1; and positive chair test, 1. Thus, the maximum prediction score is 14 points. The cutoff score to discriminate women at high risk of fracture with 90% sensitivity is 4.5. With this cutoff, 1,464 women (23.7%) were considered at low risk of hip fracture (score less than 4.5), and 4,710 (76.3%) were considered at high risk (score at least 4.5). Among these high risk women, 60 (1.3%) experienced an osteoporotic hip fracture. In contrast, 6 (0.4%) of the low risk women experienced such a fracture.

The main limitation of this predictor rule is that at a sensitivity of 90%, the specificity was only 24%.

LOS ANGELES — A prediction rule combining five easily obtainable risk factors distinguishes with high sensitivity women at high risk of developing osteoporotic fractures within the next 3 years, Dr. Idris Guessous reported at the annual meeting of the Society of General Internal Medicine.

The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk (SEMOF) study was a 3-year, prospective, multicenter study (n = 623) that computed a prediction score using low heel ultrasound stiffness index (SI), older age, fracture history, recent fall, and missed chair test to predict osteoporotic hip fractures and other nonvertebral fractures.

The objective of the study was to compute a prediction rule that would identify women at high risk of osteoporotic fracture in general, or a hip fracture in particular, within the next 3 years, said Dr. Guessous of the University Hospital of Lausanne, Switzerland.

The heel bone ultrasonometer (Lunar Corp., Madison, Wisc.) was chosen because it is simple, inexpensive, noninvasive, and transportable. Of 7,114 Swiss women who responded to a mailed request to participate, 6,174 women between 70 and 85 years old were enrolled. Exclusion criteria included previous hip fracture, bilateral hip replacement, renal failure, and active cancer.

Bone SI was calculated using quantitative ultrasound of the heel, broadband ultrasound attenuation, and speed of sound as the inputs. SI is expressed as a percentage of values obtained by the manufacturer in a young adult population. Osteoporotic fractures were defined as hip, wrist, or arm breaks that occurred spontaneously or secondary to falling from standing height or lower despite a low level of trauma.

The investigators included baseline characteristics (age, weight, height, body mass index), known risk factors for osteoporosis (fracture history, history of maternal hip fracture, current smoking habits, early menopause, surgical menopause), fall (history of recent fall, missed chair test), and SI as parameters to develop a prediction score. The investigators then used bootstrap methods to evaluate the stability of the score, Dr. Guessous said.

Mean follow-up was 2.8 years (17,546 person-years). Five risk factors were independent, significant predictors of the incidence of osteoporotic fractures: age older than 75, SI greater than 78%, history of any prior fracture, history of a fall during the last 12 months, and missed chair test (not being able to rise from a chair three successive times without using one's arms).

The investigators assigned a score to each of the five significant predictors: age, up to 3; SI, up to 7.5; history of fall within past 12 months, 1.5; fracture history, 1; and positive chair test, 1. Thus, the maximum prediction score is 14 points. The cutoff score to discriminate women at high risk of fracture with 90% sensitivity is 4.5. With this cutoff, 1,464 women (23.7%) were considered at low risk of hip fracture (score less than 4.5), and 4,710 (76.3%) were considered at high risk (score at least 4.5). Among these high risk women, 60 (1.3%) experienced an osteoporotic hip fracture. In contrast, 6 (0.4%) of the low risk women experienced such a fracture.

The main limitation of this predictor rule is that at a sensitivity of 90%, the specificity was only 24%.

LOS ANGELES — A prediction rule combining five easily obtainable risk factors distinguishes with high sensitivity women at high risk of developing osteoporotic fractures within the next 3 years, Dr. Idris Guessous reported at the annual meeting of the Society of General Internal Medicine.

The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk (SEMOF) study was a 3-year, prospective, multicenter study (n = 623) that computed a prediction score using low heel ultrasound stiffness index (SI), older age, fracture history, recent fall, and missed chair test to predict osteoporotic hip fractures and other nonvertebral fractures.

The objective of the study was to compute a prediction rule that would identify women at high risk of osteoporotic fracture in general, or a hip fracture in particular, within the next 3 years, said Dr. Guessous of the University Hospital of Lausanne, Switzerland.

The heel bone ultrasonometer (Lunar Corp., Madison, Wisc.) was chosen because it is simple, inexpensive, noninvasive, and transportable. Of 7,114 Swiss women who responded to a mailed request to participate, 6,174 women between 70 and 85 years old were enrolled. Exclusion criteria included previous hip fracture, bilateral hip replacement, renal failure, and active cancer.

Bone SI was calculated using quantitative ultrasound of the heel, broadband ultrasound attenuation, and speed of sound as the inputs. SI is expressed as a percentage of values obtained by the manufacturer in a young adult population. Osteoporotic fractures were defined as hip, wrist, or arm breaks that occurred spontaneously or secondary to falling from standing height or lower despite a low level of trauma.

The investigators included baseline characteristics (age, weight, height, body mass index), known risk factors for osteoporosis (fracture history, history of maternal hip fracture, current smoking habits, early menopause, surgical menopause), fall (history of recent fall, missed chair test), and SI as parameters to develop a prediction score. The investigators then used bootstrap methods to evaluate the stability of the score, Dr. Guessous said.

Mean follow-up was 2.8 years (17,546 person-years). Five risk factors were independent, significant predictors of the incidence of osteoporotic fractures: age older than 75, SI greater than 78%, history of any prior fracture, history of a fall during the last 12 months, and missed chair test (not being able to rise from a chair three successive times without using one's arms).

The investigators assigned a score to each of the five significant predictors: age, up to 3; SI, up to 7.5; history of fall within past 12 months, 1.5; fracture history, 1; and positive chair test, 1. Thus, the maximum prediction score is 14 points. The cutoff score to discriminate women at high risk of fracture with 90% sensitivity is 4.5. With this cutoff, 1,464 women (23.7%) were considered at low risk of hip fracture (score less than 4.5), and 4,710 (76.3%) were considered at high risk (score at least 4.5). Among these high risk women, 60 (1.3%) experienced an osteoporotic hip fracture. In contrast, 6 (0.4%) of the low risk women experienced such a fracture.

The main limitation of this predictor rule is that at a sensitivity of 90%, the specificity was only 24%.