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Effects of training and experience on rheumatology reimbursementcomment on the article by mazzuca and brandt.

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6. Maharaj B, Bhoora IG: Complications associated with percutaneous needle biopsy of the liver when one, two, or three
specimens are taken. Postgrad Med J 68:964-967, 1992
7. Fries JF, Singh G, Lenert L , Furst DE: Aspirin, hydroxychloroquine, and hepatic enzyme abnormalities with methotrexate in
rheumatoid arthritis. Arthritis Rheum 33:1611-1619, 1990
Reply
To the Editor:
We thank Dr. Fries and colleagues for their letter and
welcome the opportunity to try to address some of the issues
they have raised. We agree that the 0.1-2.5% incidence of
CSLD may represent an overestimation. The estimates
provided in Table 7 of our report were given only to illustrate
how the cost of detecting CSLD differs based on the use of
different assumptions about incidence. The fact that no case
of CSLD has been documented among the ARAMIS patients
cannot be considered proof that the true incidence of this
complication is lower than 1/1,200. Whatever the actual
incidence of CSLD is, if the suggested guidelines for downward adjustment of the MTX dosage based on the occurrence of elevations of aspartate aminotransferase (AST) or
decreases of serum albumin levels are used in patients in
whom blood samples are obtained at the recommended
frequency, then there should be even fewer cases of CSLD
and a much decreased need to perform any monitoring liver
biopsy.
The estimates for the rates of complication from liver
biopsy quoted by Fries and colleagues represent a variety of
biopsy techniques from different institutions. Although
space did not allow, nor did we feel that it was necessarily
appropriate, for guidelines on the actual conduction of a liver
biopsy to be included in our report, safety guidelines have
been described previously (1). It is clear that the risk of liver
biopsy increases with the use of a cutting needle, the number
of sticks with the needle, and the performance of biopsies in
institutions where physicians-in-training perform the procedure (2). The estimated rate of complications from liver
biopsy of 1.5% provided by Fries and colleagues is acceptable only if one assumes a series of worst-case scenarios. We
continue to believe that this figure should be close to or
under the 0.15% figure we quoted, when a Menghini type
(noncutting) suction needle is used by an experienced physician and if “second sticks” are performed only under
ultrasonic guidance as previously described (1).
We have no argument with the point about restarting
the liver function test abnormality count after an MTX
dosage reduction, which is what is recommended in both
Table 8 and the Discussion section of our report. We see no
present need to move the threshold for AST downward from
2 standard deviations above normal (the present laboratory
definition of upper limit of normal) into the normal range for
downward adjustment of the MTX dosage, until useful data
emerge showing that this is appropriate.
We chose to not precisely define prior excessive
alcohol ingestion but to leave this to the clinician’s own
judgment. If alcohol consumption is considered to be excessive, MTX should not be prescribed. We still believe that the
prevalence of hepatitis C is sufficiently large in the general
LETTERS
population that screening is justified. The hepatitis screening
panel would also give information about hepatitis B.
Dr. Fries and colleagues would like us to comment
on the potential role of either folic or folinic acid supplements in reducing liver function abnormalities. Since there
are presently no data available, we must agree that this is an
area requiring study. Finally, we must take issue with their
statement that hydroxychloroquine often normalizes AST or
alanine aminotransferase abnormalities when used with
MTX. The quoted study (3) used only a single most recent
AST sampling from a heterogeneous group of unmatched
patients and compared the frequency of abnormalities between several treatment combinations, in a retrospective
manner. We believe that a prospective, randomized, controlled study is necessary to definitively address the question
of whether hydroxychloroquine, or any other drug used in
combination with MTX, is capable of reducing both the
incidence of transaminitis and the occurrence of CSLD. We
agree with Fries et a1 that continued surveillance, including
the collection of prospective data, is needed to insure that
the suggested guidelines remain current and appropriate for
our patients with RA who are receiving MTX.
Joel M. Kremer, MD
Albany Medical College
Albany, IVY
Graciela S. Alarcon, MD
The University of Alabama
at Birmingham
Michael E. Weinblatt, MD
Brigham and Women’s Hospital
Boston, M A
1. Kremer JM: Liver biopsies in patients with rheumatoid arthritis
receiving methotrexate: where are we going? J Rheumatol 19:
189-191, 1992
2. McGill DB, Rake1 AJ, Sinzmeister AR, Ott BJ: A 21 year
experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology, 99: 13961400, 1990
3. Fries JF, Singh G, Lenert L, Furst DE: Aspirin, hydroxychloroquine, and hepatic enzyme abnormalities with methotrexate in
rheumatoid arthritis. Arthritis Rheum 33: 1611-1619. 1990
Effects of training and experience on rheumatology
reimbursement: comment on the article by Mazzuca
and Brandt
To the Editor:
I read with interest the recent article by Mazzuca and
Brandt regarding the future of clinical rheumatology training
(Mazzuca SA, Brandt KD: Clinical rheumatology training in
an uncertain future: opinions of recent and current rheumatology fellows about an extended fellowship in musculoskeletal medicine. Arthritis Rheum 37:329-332, 1994). Having
been in private practice 12 years and, in my opinion, having
developed a great deal of insight into the vagaries and
insanity of reimbursement for special services, I feel it is my
duty to write, absolutely refuting the conclusions reached by
the authors.
Certainly the data in their article do support their
conclusions. However, the respondents were given no op-
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LETTERS
tion to find another alternative. That alternative is simply a
2-year fellowship with less emphasis on rarely seen entities
and more emphasis on common disorders and procedures.
Given the choice of a 3-year fellowship program or a 2-year
program tailored more toward the changing nature of rheumatology practice, I can assure you that the respondents
would have chosen a 2-year program instead of spending yet
another year in training, getting deeper in debt, and further
delaying gratification, especially since, in the words of the
authors, the future is indeed “uncertain.”
The authors also make some statements which they
treat as axioms, but practicing rheumatologists know that
the situation is just not that simple. For example, the authors
state that the future holds a “more remunerative role for
primary care physicians.” I’m not sure that this is true. If
you look at the increasing influence of health maintenance
organization (HMOttype health plans, it is clear that physicians’ incomes will be very closely tied to how “cost
effective” they are, which is a euphemism for costing the
insurer the least amount of money possible in any given
situation.
In the upper Ohio Valley, there is a very powerful
HMO (from which I severed relations in 1988) which punishes physicians for ordering “too many” tests, performing
“too many” procedures, and obtaining “too many” consultations. Often, physicians must pay “sanctions”amounting to thousands of dollars-back to the HMO for
doing what they felt was right for the best care of their
patients. Medicare is another example of how training and
experience do not seem to matter in terms of remuneration.
If I am asked to see a Medicare patient at the hospital for
consultation, for example, and I feel that it is imperative to
aspirate a swollen joint to rule out sepsis, gout, etc., it is my
understanding that I am paid for either the consultation or
the procedure, but not for both.
Given these facts, how is a rheumatologist better
positioned to escape economic catastrophe if he or she
learns to do electromyograms, biopsies, etc.? Not only will
the rheumatologist probably not be reimbursed in a manner
that is fair, but if Congressmen Stark and Dingle have
anything to say about it, the rheumatologist might well be
brought up on charges of fraud because of the “self-referral”
of the patient for such testing, which of course, would be
done by the rheumatologist so trained.
In summary, I think that the idea of a 3-year rheumatology fellowship is a bad one. I think a reasonable
alternative would be a 2-year fellowship with more emphasis
on musculoskeletal medicine. However, even if this came to
pass, the reimbursement for services will probably dwindle
in proportion to the size of the federal deficit.
Thomas J. Romano, MD, PhD
Wheeling, WV
Reply
To the Editor:
We thank Dr. Romano for his interest in our survey
of rheumatology fellows. We share his concerns regarding
the impact of managed care systems on optimal care of
patients with rheumatic diseases. And we appear to agree on
the desirability of an optional programmatic emphasis in
musculoskeletal medicine within rheumatology fellowships.
However, we must agree to disagree on certain curricular
parameters.
Dr. Romano asserts that the solution is “. . . a
2-year fellowship with less emphasis on rarely seen entities
and more emphasis on common disorders and procedures.”
While there may be a niche in the health care system for a
physician so trained (i.e., skilled in the diagnosis and management of regional musculoskeletal pain syndromes and
other common musculoskeletal disorders), if that emphasis
comes at the expense of expertise in the diagnosis and
management of systemic lupus erythematosus, vasculitis,
dermatomyositis, and other “rarely seen entities,” we
would be hard-pressed to consider that physician a rheumatologist.
Any prospective fellow is an investor. He or she
invests time in the anticipation of a worthwhile intellectual
and monetary pay-off. Our data suggest that there may be a
sizable number of potential trainees who would seriously
consider investing an additional year in training to augment
traditional rheumatology expertise with a broader array of
cognitive and procedural competencies in common musculoskeletal disorders. Our survey was not designed to gauge the
popularity of training in musculoskeletal medicine as an
alternative to traditional learning experiences and expertise
in rheumatology.
Steven A. Mazzuca, PhD
Kenneth D. Brandt, MD
Indiana University School of Medicine
Indianapolis, IN
Collagenase and stromelysin expression in rheumatoid
synovium and cartilage: comment on the article by
Wolfe et a1
To the Editor:
We read with interest the paper by Wolfe et a1
concerning the in vivo expression of collagenase messenger
RNA (mRNA) in synovium and cartilage (1). We do have
some concerns regarding the data presented and the conclusions that were drawn from it.
In the Introduction and Methods sections the authors
state that some of the samples were snap frozen and,
presumably, RNA was extracted at a later date. Considerable RNA degradation can occur when tissue is frozen for
more than 3 months without guanadine isothiocyanate to
inhibit RNase activity. It would be helpful to know how
much time elapsed between the snap-freezing step and RNA
extraction. In the frozen samples, we would question
whether degradation occurred during storage of the frozen
tissue.
The Northern blot presented as Figure 1 illustrates
the levels of stromelysin mRNA and collagenase RNA in
osteoarthritis and rheumatoid synovium and cartilage. Analysis of the blots reveals that synovial stromelysin is preferentially expressed compared with collagenase. The authors,
however, conclude the opposite. Their conclusion may be
based on the other 23 samples that are listed in Table I , but
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