At a Council for American Medical Innovation meeting held earlier this week in Washington, Marc Boutin, executive vice president and chief operating officer of the National Health Council (NHC), recalled how his father died of lung cancer several years ago.
"He spent a year-and-a-half on chemotherapy treatment that did absolutely nothing for him except diminish the quality of his life. We only learned after he died that just 10% of the population responds to that treatment—and yet almost everybody with lung cancer gets that same chemotherapy regime," Boutin said. "If we had known that, I'm not sure that we would have continued through with that treatment."
But changes are afoot for the millions with chronic diseases and disabilities, including those represented by the NHC, in the form of biomarkers, which can be used to diagnose disease risks, assess the presence of disease in an individual, or tailor treatments for the disease in an individual—using drug treatments or administration regimes.
Citing a recent report by PriceWaterhouse Coopers (PWC) on "Moving Toward Personalized Medicine," Boutin said that "we expect that almost all specialty products will have a companion biomarker diagnostic."
This means that it will become easier to tell who "a product will work for and who it will not work for, and we'll be able to pinpoint the treatment right to the person," Boutin said. The big question, though, is: How long will it take?
In the PWC report, the researchers looked at the year 2020 as when biomarkers will be readily available and used. But to Boutin, that's 11 years too late—especially because much of the technology exists now.
Recently, the NHC did some research to look at what are some of the barriers to quicker adoption. He cited several that are contributing to the uncertainly on developing biomarkers:
Very little guidance is available as to how a biomarker would be approved by the Food and Drug Administration as a diagnostic, Boutin said. "There is a lack of coordination between the approval arm of the FDA and the safety arm of the FDA."
There are very low reimbursement rates for these groups. "We need to address how the Centers for Medicare and Medicaid Services (CMS) looks at reimbursement of diagnostics. And, we also have to look at how the private sector addresses reimbursement issues in this market," he said. "There are really not a lot of incentives when you start to look at the private sector to address this."
A number of types of biomarkers do exist. Some of them will indicate, for instance, "that if you take this medicine, you're going to have really bad adverse reactions," Boutin said. "That's a great biomarker to have. Other kinds of biomarkers actually tell you how who this will not work for.
"Quite honestly, that would have been very helpful in my father's situation. Had he known that chemotherapy would not work for him, he would have spent that last 18 months of his life not going through the trials and tribulations of chemotherapy," Boutin said.
"But the reality is that negatively impacts your business market. If you're going to determine who your product does not work for, you have less of a market share. So we have to look at some other incentives for industry," he said.
"We need to create a new business model. We need to figure out how we can develop trials...that give conditional approval to these kinds of biomarkers, with the subpopulations that have been identified where it works," he said.
"We need to speed up the development of these new diagnostic mechanisms and put them out into the market and test them," he said. "I can tell you from this perspective that people with chronic conditions . . . are much more willing to accept risk than we give them credit."
Many of these individual are "very interested" in having diagnostics developed—if not for themselves but for their children who may have the same conditions down the road, he said. "There are real opportunities here to create incentives to get these into the marketplace far quicker than 11 years from now."
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In light of a $24 million lawsuit filed by a doctor against Johns Hopkins Hospital in Baltimore claiming that he was unlawfully fired earlier this year, how can hospitals prepare for legal troubles?
Oscar Serrano, MD, a former surgical resident, says he was fired because he refused to lie on the ACGME Resident Survey, according to the Associated Press.
Serrano's lawsuit states the firing was unlawful because there's not enough evidence of poor performance as his evaluations only showed high marks, according to the Maryland Daily Record.
Unfortunately, lawsuits are unavoidable in graduate medical education (GME).
"Whether or not a person sues is outside of your control, but you can manage how you're going to deal with the lawsuit, take preventative measures, and anticipate certain problems," says Franklin Medio, GME consultant and former designated institutional official.
The best way to prepare for lawsuits is to ensure your policies, procedures, and documentation are in order. Competency-based evaluations and feedback are a key component to noticing red flags in resident performance. Evaluations should include objective and narrative components and should be viewed by relevant faculty.
"There should be documentation that the person had performance problems [and] they were counseled about those problems," Medio explains, adding that due process policies should be reviewed by hospital legal departments.
By the time you get to the point that you're firing a resident, he or she should not be hearing about problems for the first time. However because both faculty members and residents have little experience with giving—or asking for—feedback, performance problems are not always communicated effectively. Consider hosting educational sessions for faculty members that explain not only why feedback is important, but also how to make it effective. Similarly, they can teach residents how to request and receive feedback effectively.
Regarding the ACGME Resident Survey, programs can only go as far as helping residents comprehend the language used in the questions.
"You can make sure residents understand what certain words mean in their educational context, but nobody should be forcing residents to say certain things or lie," Medio says.
Additionally, site visitors question residents about problems identified on the survey or in anonymous complaints during a site visit to determine if they are real issues or just one resident's opinion or experience.
"The site visitors are pretty savvy about putting things into context," Medio says.
Julie McCoy is the associate editor for the Residency Department. For more residency information, visit www.residencymanager.com.
Though many popular Web sites have strong privacy practices in place, there is still no better time to analyze where, when, how, and if your personal health information (PHI) is circulating through these types of Web sites.
The Ponemon Institute and TRUSTe released its 2009 Most Trusted Companies for Privacy Award recently and ranked eBay, Verizon, the US Postal Service, WebMD, and IBM as the top five. But health leaders must also beware of employees sending any PHI on the Internet.
The last thing you want is to get burned because someone in your organization without authorization sent PHI across Yahoo!, Facebook, or similar sites.
It's not common—though it's possible—for healthcare workers to use these sites to intentionally and maliciously violate patient privacy laws.
More often, healthcare workers sign on during breaks, or when they are off work, and vent about their day with friends without realizing that they share identifiable information and violate HIPAA.
Regardless of how you respond to these privacy and security vulnerabilities, education is crucial, says Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR and a HIPAA expert.
"A lot of people are panicking," Apgar says. "But one thing that's not well understood is the danger related to all this."
Transmission over an unsecure network is inevitable, particularly if the sender and the receiver don't share a secure network, says Apgar.
Combat this with these four education models:
New employee training (orientation)
Annual refresher training
Security reminders (weekly helpful e-mails; information in hospital newsletters; and flash reminders on staff computer monitors)
Communications policy—as with confidentiality agreements, require staff members to acknowledge in writing that they have read and understand it. Do this annually at staff performance reviews.
An article in the September issue of the Journal of the American Medical Association entitled "Online Posting of Unprofessional Content by Medical Students," revealed that 60% of 80 medical school deans reported incidents involving unprofessional postings on these types of Web sites.
Another 13% acknowledged incidents that violated patient privacy. Some of these violations resulted in expulsions from medical school, according to the article.
"These professionals are well educated, but that doesn't mean they are savvy with security," says Apgar.
The finality of disclosures on these types of Web sites is what makes it so dangerous, says Apgar.
"Once you put something out there, it's out there, and it's never coming back," he says.
Simply banning these Web sites from the hospital network is one strategy that many organizations use, Apgar says.
Spring Harbor Hospital, in Westbrook, ME, doesn't allow access to Web sites, such as Facebook, on facility computers, says Chris Simons, RHIS, who serves as the facility's director of HIMS and privacy officer.
"We also include it in orientation as a no-no," she says. "We have had some issues with staff on Facebook saying inappropriate things about their managers, and have addressed that."
Access to personal e-mail accounts is just as dangerous for many reasons, and organizations are beginning to ban this practice as well.
A physician who logs onto a personal Yahoo! Mail account to send himself or herself a list of patients to access at home is one example of inappropriate use, Apgar says.
That's a breach of a lot of information, says Apgar. The hospital network may be encrypted, but the information won't be on the other side once the physician opens the e-mail at home.
Freelancer Corey Goodman contributed to this report.
U.S. employers will see medical benefit expenditures increase 7% in 2010, pushing the average annual per-employee costs for healthcare across the $10,000 threshold, according to Towers Perrin's annual Health Care Cost Survey.
The survey is also projecting components under consideration in healthcare reform legislation—such as an excise tax on so-called Cadillac health plans—could potentially increase the cost burden for employers, who will pass those additional costs to employees, exacerbating the affordability gap.
The 7% rise in 2010 marks the sixth consecutive year of single-digit percentage increases, but it also means record-high costs for both employees and employers. While employers will continue to fund 78% of the cost of the benefits in 2010, employee premium contributions, on average, will rise by 10%, or just more than $200 next year. The increase for employees was 8% in 2009. This additional burden is exacerbated by indirect cost shifting through benefit design changes, such as increased copayments and other out-of-pocket expenses, which add to the overall employee cost.
"For employees, the affordability challenges associated with this year's cost increases are even more acute than the general survey numbers suggest," says Dave Guilmette, managing director of the Towers Perrin Health and Welfare practice. "The cost-shifting actions employers are taking for 2010 are consistent with what's been done in years past, which is surprising in an economy where bigger shifts might be expected."
Guilmette says the increased employee cost in healthcare is part of a triple whammy for workers who also face flat or declining wages, and reduced 401(k) matches and balances. "The financial hardship associated with rising employee costs is top of mind—and not sustainable for many people," he says.
The Towers Perrin 2010 survey includes data on health benefits provided by 300 of the nation's largest employers, which total 5.2 million employees and their dependents, who collectively spend $29.4 billion on healthcare every year. The average reported cost of medical coverage is $5,124 annually ($427 per month) for active employee-only coverage, $10,500 annually ($875 per month) for employee-plus-one-dependent coverage, and $15,084 annually ($1,257 per month) for family coverage.
The excise tax on Cadillac plans, which has been under consideration in the Senate, would apply, beginning in 2013, to health programs with combined coverages—medical, dental, vision, flexible spending accounts, etc.—valued at more than $8,000 per year for individuals and $21,000 for families. More than 50% of companies in the Towers Perrin survey will hit the caps within the next three years if current cost trends continue, and the impact of the caps will increase over time, even with indexing on the tax thresholds after 2013.
"Given that employer healthcare costs have increased approximately 150% over the last decade, it's not surprising that companies are nervous about reform efforts with the potential to increase costs even further," Guilmette says. "In fact, our recent healthcare reform survey found that nearly half of employers believe that a pay-or-play mandate would have a negative impact on their business."
The Towers Perrin study found that only 11% of companies were willing to absorb higher healthcare costs by accepting reduced profits. For many of them, any reform-related cost increases would result in benefit cuts—and higher costs for employees and even customers.
The survey found growing support among businesses for account-based health plans, also called consumer-directed health plans, which have lower actuarial value than traditional health plans and could help employers delay hitting excise tax cap limits by up to two years. Employer adoption of ABHPs has risen significantly over the last five years, from 20% to 60% of companies.
Premium costs for a traditional ABHP are $8,927 per employee annually, which is 13% less than the average traditional plan and unused account funds roll forward to defray future out-of-pocket costs. And as noted, the lower cost of these plans also provides employers with a solution to hold family benefit values below the proposed $21,000 excise tax cap.
The 2010 survey data reinforce a consistently significant difference between healthcare costs facing high- and low-performing employers, with high performers paying 16% less—roughly $1,800 per employee—for their health benefit programs.
"In the current healthcare reform environment, high performers' benefit management decisions would actually buy them significantly more time before they hit the proposed excise tax cap," says Ron Fontanetta, Towers Perrin principal. "And when combined with an ABHP, the cost advantage means high performers would be able to insulate themselves from the excise tax cap by four more years than their low-performing peers. High performers are poised to take full advantage of this benefit: Approximately two-thirds (67%) of these companies offer ABHPs, compared with just 40% of low performers."
The good news about the physician shortage is that government leaders and academic experts finally agree that there is one.
For years, most policy makers and academics took the opposite view, arguing that the United States had too many physicians and that a limit should be put on the number of doctors being trained. Their arguments prevailed, and in 1997 Congress capped Medicare funding of physician graduate medical education. The number of physicians trained in the United States each year has been virtually frozen at about 24,000 since.
The pendulum has finally swung the other way, however, and the majority of experts now concede that there is a dearth of doctors, particularly in primary care. The Association of American Medical Colleges, for example, projects a deficit of 159,000 physicians by 2025. At least 15 medical specialty societies have released studies projecting shortages in their fields. The Lewin Group, a research company based in Washington, D.C., projects that universal coverage would drive the need for 35,000 additional physicians.
The Obama administration has clearly signaled that it understands more physicians will be needed in order to deliver on the promise of expanded access to healthcare.
To date, some action has been taken to increase physician supply. The Obama administration has earmarked $200 million in federal stimulus money to boost the ranks of the National Health Services Corps by 3,300 physicians and other clinicians. It also has reiterated the need to restructure physician reimbursement to more robustly reward primary care physicians for their role in managing care and implementing preventive services. There is also hope that new practice and reimbursement structures, like the medical home, will reignite medical student interest in primary care.
However, the surest way to make a real dent in the shortage is to lift the cap on Medicare funding of medical residency programs. Several bills have been introduced to Congress that would do so, including one submitted by Senator Bill Nelson (D-FL) and Congressman Joseph Crowley (D-NY) that would increase residency slots by 15%.
This would come at a cost of several billion dollars a year—not a significant part of Medicare's overall budget, but possibly prohibitive given current federal budget constraints. So far, none of the bills aimed at increasing physician supply appear to have gained traction, and it is far from clear whether or not residency programs will be expanded anytime soon.
What is clear is that the physician shortage would be considerably worse without the presence in this country of tens of thousands of international medical graduates (IMGs). Foreign-born graduates of international medical schools now comprise about 20% of all physicians in active patient care in the United States. In some specialties, such as cardiology, internal medicine, psychiatry, and nephrology, they comprise 30% or more of all active physicians.
About 6,000 IMGs complete residency training in the United States each year. Many of them remain here, often practicing in underserved areas to meet visa requirements. Others would like to stay but eventually practice elsewhere due to annual visa quotas and other immigration restrictions. These quotas and restrictions should be removed to ensure that any physician trained and qualified to practice medicine in the United States. has the option of doing so.
Unfortunately, this in itself will not solve the physician supply problem. It is time to consider opening U.S. medical practice to physicians who have trained elsewhere. Today, only physicians trained in Canada are permitted to obtain a medical license in the United States without completing a U.S.-based residency program. Canada's medical licensing exam and residency training programs are deemed to be equivalent to those in the United States. Physicians trained in every other country must complete a U.S.-based residency program to qualify for a medical license.
In the past, this policy has been a safeguard that has helped ensure a high standard of care. Today, however, there are thousands of highly-trained physicians from Europe, Asia, and elsewhere who, on a case-by-case basis, have the skills and commitment to contribute to the quality of care available in this country. In fact, a growing number of patients from the United States are traveling abroad to receive care from these doctors. This trend is likely to accelerate as the physician shortage makes access to doctors in the United States increasingly problematic.
It makes little sense to lose these patients or the care and innovation that select international medical graduates could provide. Can it be possible that only physicians trained in the United States and Canada have the skills to provide quality patient care? The time to seriously rethink this notion has arrived.
Carl Shusterman served as a trial attorney for the U.S. Immigration and Naturalization Service and is principal of the Los Angeles-based Law Offices of Carl Shusterman. He can be reached atcarl@shusterman.com.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
Some types of CME seem to be more effective than others and researchers are trying to understand why. Saul Weiner, MD, deputy director at Jesse Brown VA Medical Center and associate professor of medicine and pediatrics at the University of Illinois at Chicago, along with his colleagues, set out to explore this question.
They asked three CME providers presenting at a national Society of General Internal Medicine meeting to develop questions to assess what participants knew and felt about a particular subject before, immediately after, and nine months after a CME intervention. Participants were asked these questions immediately after the CME session and nine months later.
Participants in all three sessions demonstrated that they had gained knowledge immediately following the session.
Those who participated in a 90-minute session on research methods reported a modest gain in knowledge, whereas those who participated in an eight-hour research precourse experienced a large gain. A 90-minute clinical workshop produced a moderate gain in knowledge.
But participants in two of three sessions reported that they did not retain that knowledge after nine months.
"We don't know why there is variation, but with this small study, we can show that there is variation," says Weiner.
This article was adapted from one that originally appeared in the October 2009 issue of The Doctor's Office, a HealthLeaders Media publication.
If your revenue increased or even stayed the same during the beginning of the recession, then you're doing better than many physicians. The median total revenue in medical practices declined—for the first time in years—by 1.9% in 2008, according to MGMA's latest cost survey.
And revenue wasn't all that dropped. The median number of patients visiting medical groups fell by nearly 10%, and the overall number of procedures declined 11.6% between 2006 and 2008. During that same period, bad debt from fee-for-service charges jumped roughly 13%.
This new information offers some statistical validation for trends that many in the healthcare field have already witnessed firsthand. Patients are cutting back on elective procedures in hard times. In some cases, they're forgoing necessary medical care because they are newly uninsured after a job loss. Or they're struggling to pay their bills after a visit, leading to that increase in bad debt.
The publicly-funded safety net is becoming increasingly strained, as well. In many states, Medicaid rolls are higher than they've ever been—Medicaid covered about 42.6 million people in 2008, up 7.6% from 39.6 million in 2007—and governments are starting to cut reimbursements to physicians in order to ease the pressure on budgets.
Physicians seem to be surviving the way most businesses keep going when revenues disappear—they're cutting operating costs. According to MGMA data, practices reduced overhead expenses in 2008 by about 1.5%, and much of that came from support staff, which dropped in the survey for the first time in a while.
Overall, staffing levels stayed about the same in aggregate, which may indicate that some groups hired while others laid off workers, and it has evened out in the wash. It's also likely that healthcare workers, like employees in almost every sector, are forgoing raises or even taking pay cuts for the time being.
Keep in mind, this data is from 2008. Fresher data from 2009 will likely show an even drearier financial situation for medical groups, as many of the indicators have gotten worse this year.
When the healthcare economy will turnaround is tough to predict. There are already a few green shoots that suggest the U.S. economy has at least bottomed out—the stock market has been on a tear since March and the latest GDP estimates have been better than initially predicted.
But an improving economy doesn't mean physician financial woes will end soon. The underlying factors that have hurt medical groups are unemployment and strains on safety net programs, and those may actually get worse as the rest of the economy improves. Economists are predicting a jobless recovery initially; unemployment may climb past 10% while the rest of the economy rebounds. That means more patients losing their insurance or migrating to already bloated Medicaid rolls, and possibly further reimbursement cuts. And it means more revenue struggles for medical groups.
The old conventional wisdom that said healthcare is recession proof has been soundly dispelled by the current downturn. The new conventional wisdom is that healthcare is one of the last sectors to be affected by a recession, but also one of the last to recover.
It's still too early to tell if there's any wisdom in that.
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Three in 10 elderly patients who sought care in an emergency room after a fall were admitted to the hospital for treatment of their injuries, which was a major share of the $20 billion cost for treating falls in people over age 65 in 2006.
Since 2006, fall-related health costs are believed to have increased substantially because of a larger number of seniors suffering falls, and because of the higher costs of treating the fractures, open wounds, and head traumas they cause.
Those were two findings from a new report from the federal Agency for Health Research and Quality, which said that each year, about one-third of elderly adults experiences a fall. Falls are the most common cause of non-fatal injuries in the senior population.
"Because many falls are preventable and their impact on the U.S. healthcare system is significant, it is important to better understand the types of fall-related injuries experienced by elderly adults, particularly those injuries requiring treatment in an ED," wrote the authors Pamela Owens, C. Allison Russo, William Spector, and Ryan Muter, who are analysts for the agency.
Throughout the country, many healthcare systems are working on programs to help older people maintain their sense of balance, wear better shoes, and get more exercise to maintain muscle strength. Nevertheless, many older people don’t realize their increased vulnerability to fall-related injuries as they age.
Here are some highlights from the report:
Falls prompted 2.1 million elderly adults to seek care in emergency rooms in 2006, and accounted for one in 10 emergency visits among patients age 65 or older.
The cost of hospital care to treat fall-related injuries among seniors was $6.8 billion of the $20 billion in 2006.
Falls among women over age 84 were more frequent, one in seven, compared with falls among men over age 84, one in 10.
Fractures were the biggest reason for fall-related injuries among seniors, accounting for 41% of emergency room visits after a fall. Superficial injuries or contusions accounted for 22.6%, and open wounds 21.4%.
Hip fractures accounted for one in eight injurious emergency room visits among the elderly.
Those seniors who were admitted to the hospital for treatment due to a fall were more likely to be discharged to a long-term care facility than elderly patients admitted to the hospital for other conditions.
The cost of caring for elderly patients hospitalized because of fall-related injuries was on average higher than the cost of treating elderly patients admitted with other conditions, a difference between $10,800 and $9,900.
Congressional Budget Office (CBO) preliminary estimates are in, and the bill approved by the Senate Finance Committee early last Friday morning comes in at $829 billion over 10 years—an amount roughly 8% below what was initially predicted by panel chairman, Sen. Max Baucus (D-MT).
The cost mainly reflects credits and subsidies provided through state insurance exchanges, increased outlays for Medicaid and the Children's Health Insurance Program (CHIP), and tax credits for small employers. Those costs will be partly offset by $201 billion in revenues from excise taxes proposed on high premium—or "Cadillac"—insurance plans and $110 billion in savings from other sources.
In a letter to Baucus and Sen. Charles Grassley (R-IA), the panel's ranking minority member, CBO Director Douglas Elmendorf said the measure is expected to reduce the overall federal budget deficit by $81 billion over 10 years because the reforms, as proposed, will reduce healthcare costs.
The $829 billion would be offset as well by spending changes related to Medicare and other federal health programs (by $404 billion over the next decade), and by placing fees on insurers, pharmaceutical and medical device manufacturers, and other areas of the healthcare industry that could gain financially with potential inclusion of the 29 million new nonelderly customers added under reform legislation.
Roughly 23 million people could purchase their own coverage through the new insurance exchanges, and an estimated 14 million more would become enrollees in Medicaid and CHIP. Overall, the share of nonelderly residents with insurance coverage would rise from about 83% currently to about 94%. Approximately 25 million nonelderly residents would be left uninsured—about one third of whom would be illegal immigrants.
Elmendorf also said in the letter that overall, the added revenues and cost savings "are projected to grow more rapidly than the cost of the coverage expansion." Those estimates, though, "are all subject to substantial uncertainty."
Some of the variables noted in the CBO correspondence is the creation of a Medicare Commission. As proposed in the Senate Finance bill, the commission would recommend changes to Medicare "to limit the rate of growth" in that program's spending. CBO said that its projected longer term savings for the proposal assumes that the commission "is relatively effective in reducing costs"—beyond other proposed reductions.
The final vote on the Senate Finance Committee bill could come as early as Friday, but several GOP members have asked that Elmendorf and Thomas Barthold, chief of staff of the Joint Committee on Taxation, be present when the committee reconvenes. "Before the committee votes to report the legislation out of Committee, it is important that all members have a thorough understanding of the cost of the legislation and how individuals, families, and businesses will be affected," Grassley wrote in a statement earlier this week.
Sen. Olympia Snowe (R ME), one of the Republicans on the committee who could support the bill, urged Baucus not to force a vote before next week and added she has remained noncommittal. "We have a lot to review," she said.
On the House side, Ways and Means Committee Chairman Charles Rangel (D NY) said that he intends to submit the House healthcare reform bill to CBO by Friday for review. Rangel met yesterday behind closed doors with Baucus.
Senate Majority Leader Harry Reid (D-NV) said he wants to combine the bill by next week with the Senate Health, Education, Labor and Pensions Committee bill, and then present that bill to Senate floor later this month.
Scripps Health is saying it is the first U.S. hospital network to bring its heart care into the world of genetic medicine by offering a test to determine which stent patients may benefit from anti-platelet drug therapy, and which ones won't.
The Scripps announcement follows the Journal of the American Medical Association's August publication of a study that found "compelling evidence" that people with gene mutations, CYP2C19•2, have a poorer response to treatment with clopidogrel (Plavix) than people without the mutation.
While the genotype accounted for approximately 12% of the variation in clopidogrel response, the authors wrote, "with age, BMI and lipid levels, approximately 22% of the variation in clopidogrel response can be explained."
The drug is the second-most commonly prescribed in the U.S. and is commonly given to one million patients a year after they undergo coronary stent procedures.
"Patients who have the reduced function allele have a 50% higher risk of having a cardiovascular event" because of lack of response to clopidogrel, says Matthew Price, MD, director of the cardiac catheterization lab at Scripps Green Hospital in La Jolla, CA.
The four undesirable gene mutations the test will look for occur in 30% of people of European descent and in more than 40% of those with African or Asian ancestry.
In collaboration with Quest Diagnostics, which offers a saliva version of the test, Scripps is offering the screening test for the mutations just to Scripps Clinic patients, who are scheduled for elective stent procedures at the Scripps Green Hospital next door. Price expects about 70 to 100 of the 250 patients who undergo angiography each month will be offered the test, and most will agree.
Price says Scripps Green performs approximately 1,800 elective stent procedures annually, of which 70% are elective. The genetic tests will be made available to all elective stent patients, though some may not be candidates for alternate therapies for various reasons.
"This represents a landmark program in individualized medicine based on considerable new data and new choices for one of the most commonly prescribed medications and medical procedures in the world," cardiologist Eric Topol, MD, chief academic officer of Scripps Health, said in a statement. "This program demonstrates Scripps Health's commitment to being at the forefront of individualized cardiovascular medicine."
It is expected that the majority of insurance providers will pay for the test if the patient is scheduled for angiography with the possibility of stent insertion (less copayments or deductibles). However, Medicare, which pays $200 for the test, will be billed for those beneficiaries, according to a Quest spokeswoman.
Patients at other Scripps system hospitals may be offered the test as the program gets off the ground, Price says.
For those patients found to have the mutation, knowledge will enable different forms of treatment to overcome their resistance to clopidogrel, Price says. Some patients with weak response to the drug will get more of the drug, while others may be given other drugs, such as prasugrel or cilostazol.
Some patients will receive the normal dose of clopidogrel, but with intense monitoring, such as platelet function testing, to make sure they do not experience platelet clotting.
Scripps Health says it provides more cardiovascular care than any other provider in California, with 45,000 cardiovascular patients last year.
In an editorial accompanying the JAMA report, Deepak Bhatt, MD, of the VA Boston Healthcare System and Brigham and Women's Hospital in Boston, wrote that the study "moves closer to fulfilling the promise of pharmacogenomic testing in tailoring antiplatelet therapy to the individual patient.
"Strides toward individualized therapy have already been made in cancer care and human immunodeficiency virus treatment. Antiplatelet therapy seems well suited to a tailored approach, and future investigations should pursue this promising area," Bhatt added.
