Newsletter LXIII April 2005
Contents
Assembly Bill Outlines Mandates for Reporting of Office Procedures
Malpractice Filings Against Health Care Providers, Jan 2001 – Feb 2005
Federal funds for public health in jeopardy
Clark County Health District Disease Statistics – February 2005
Assembly Bill Outlines Mandates for Reporting of Office Procedures
By
Weldon (Don)
Assembly Bill 120, sponsored by 23 Assembly Democrats (22 constitutes a majority in the Assembly) has been assigned to the Assembly Commerce and Labor Committee, chaired by Majority Leader Barbara Buckley. Currently legislative rules require that Bills be passed out of committees by April 15th and out of the first house by April 28th. Co-sponsors in the Nevada Senate are Senators Carlton, Care, Coffin, and Titus. Having more sponsors in the Assembly than is required to pass a Bill out of that House, it is virtually certain that this Bill will pass from the Assembly to the Senate.
This Bill, should it become law in its present form, would require all M.D. and D.O. licensees to submit with their application for renewal of licensure a report stating the number of surgeries requiring conscious sedation, deep sedation, or general anesthesia performed by the licensee at his (or her) office … during the most recent period of licensure. Next, the licensee must describe the surgical care performed on each patient including the type and dosage of anesthesia administered to each patient. This latter reporting mandate is not restricted to office procedures, but would include all surgical procedures performed by the licensee, apparently anywhere. Lastly, the licensee must report the occurrence of any sentinel event arising from any surgery requiring conscious sedation, deep sedation or general anesthesia performed by the licensee. Sentinel event is defined as any "unexpected occurrence involving death or serious physical or psychological injury or the risk thereof, including, without limitation, any process variation for which a recurrence would carry a significant chance of serious adverse outcome. The term includes loss of limb or function."
These mandates apply to all licensees of the Nevada State Board of Medical Examiners and the Nevada State Board of Osteopathic Medicine. According to the Legislative Counsel's Digest explanation of the Bill, the Boards would be required "to include in their biennial reports to the Governor and Legislature information received from licensees regarding office-based surgeries involving sedation or general anesthesia."
If the Bill is intended to only apply to office-based surgeries, it needs to be amended to so indicate in the text of the Bill. If the authors of the Bill intend to make information available to the public regarding every surgical procedure performed with sedation by a Nevada-licensed M.D. or Nevada-licensed D.O., the Bill is correct as written. There is no requirement that patients be identified by name, so the confidentiality of patients appears to have been considered. Interested members of the public would appear to be able, under the Public Records Act, to contact the respective Boards for this information regarding any particular reporting licensee. There is no provision in the Bill to respect the confidentiality of the reporting physician.
Would the news media find this a source of information of interest to the public? Could we find a biennial "special section" of our local newspapers listing licensees' and the number of sedation related procedures performed and all sentinel events arising from those surgeries? Will the sentinel event reports serve as a rich source of potential medical malpractice liability plaintiffs? Will this Bill, if it becomes law, encourage physicians to perform surgeries without sedation (and thereby avoid the reporting requirement on those patients)? Curiously, this legislation would not require reporting of a sentinel event (death, loss of limb, etc.) unless sedation was used in the surgery.
If
Nevada-based licensed physicians will find this reporting onerous, what will be
the impact on Nevada-licensed physicians practicing in other states? The Bill applies to ALL licensees of the
respective Boards, not just physicians located in
How will the costs of this program be paid? By requiring the boards to accumulate the data, it will likely require each Board to add a staff member just to comply with the mandates in AB 120. The costs will necessarily be borne by the physician licensees of those respective Boards. The two Boards are already swamped with work from the investigation mandates in SB 250 of the last legislative session and from the mandates in A.B. 1 of the 2002 special session. To meet these mandates, the Nevada Board of Medical Examiners has increased its staff such that Board salaries last year alone exceeded the total cost of operation of the Board in 2001. Licensure renewal fees, already at a record high, are likely to increase.
One may ask what problem this legislation is intended to address? If reliable documentation demonstrates that there are an unacceptably large number of Nevadans being injured in office surgeries (or surgeries in general), where is that data? If there is valid data, will this solution correct the problem?
With 27 Democratic legislators, and not a single Republican legislator, serving as sponsors or joint sponsors of this Bill, some physicians have speculated that this is a partisan effort with ulterior motives unrelated to someone's notion of a "good idea". One physician recently quipped that if the road to hell is paved with good intentions, this Bill ought to be worth a few miles of asphalt.
Clark County District Court Medical Malpractice Filings Against Health Care Providers, Jan 2001 – Feb 2005
2001 2002 2003 2004 2005
Jan 39 33 108 61 41
Feb 20 14 98 72 63
Mar 35 30 169 123
Apr 37 34 111 81
May 37 35 126 65
Jun 27 24 103 90
Aug 54 51 76 67
Oct 37 83 110 59
Nov 38 184 59 78
Sum 372 823 1246 867
New Members – February 2005
- David T C Chan, MD, Family Practice, 11201 S Eastern Ave #110, Henderson, NV 89052
- Ethan M Cruvant, MD, Internal Medicine, 3006 S Maryland Pkwy #750, Las Vegas, NV 89109
- Russell T Nevins, MD, Orthopaedic Surgery, 2650 N Tenaya Way #301, Las Vegas, NV 89128
Applicants To Go Before Credentialing Committee
If you have any pertinent information about the following membership candidates, please contact:
· Aury N Nagy, MD – Neurological Surgery
· David J Snell, MD – Anesthesiology
For information on becoming a member of the Clark County Medical Society, call Marlaina Burns at 739-9989
Diagnosis and Treatment of Pharyngitis: A Practical Guide to Diagnosis and Treatment of Infection in the Outpatient Setting
Submitted by Nevadans
for Antibiotic Awareness
Pharyngitis is one of the most common illnesses encountered by primary care physicians in the outpatient setting. The most common bacterial, and therefore treatable, cause of acute pharyngitis, is group A streptococcus, or Streptococcus pyogenes. In children, group A streptococcus causes 15 - 30% of cases of pharyngitis. However, only 5-to10% of all adult cases of pharyngitis are bacterial; the remainder are due to viruses. In spite of the low prevalence of streptococcal disease, almost three quarters of all adults presenting to a primary care physician with a sore throat are prescribed an antibiotic, 68% of these were prescribed broader spectrum, more expensive antibiotics than those recommended. Therefore, it is in the setting of pharyngitis that we find more antibiotic overuse and misuse than with any other diagnosis.
Rationale for treating streptococcal pharyngitis. There is no rationale for treating viral pharyngitis. Perhaps the reason so many patients with viral infections are treated with antibiotics is the fear of sequellae of untreated streptococcal infections, as well as the fear of potential litigation if the diagnosis is missed. However, the risk of post-streptococcal complications is very low, and in adults it is almost negligible.
Acute rheumatic fever is the most
feared post-streptococcal syndrome that is effectively prevented by treatment
of the acute infection. Although rampant in other countries around the world,
it is relatively rare in the
Peritonsilar abscesses are a potential complication of streptococcal pharyngitis. Antibiotic treatment of pharyngitis prevents progression to abscess formation, however it is very uncommon even without treatment.
Another reason one might treat streptococcal pharyngitis is to reduce symptoms. However, this is a self-limited disease and will resolve without treatment. Recent data suggests that antibiotic treatment shortens the duration of illness only by about one day.
Transmission of the infection can be prevented by the use of antibiotics, but this is only significant in the pediatric population in which the risk of spread is highest. Transmission of group A streptococcal infection from adults is nearly zero. Therefore, this is not an acceptable reason for treating adults.
How to decide who receives antibiotics. Studies have shown that experienced physicians can correctly diagnose streptococcal pharyngitis by clinical criteria alone only 35 to 50% of the time. This means that a diagnosis of streptococcal infection can't be achieved just by having the patient say "ahh".
The presence of cough, runny nose (coryza), sneezing and conjunctivitis are indicators of a viral infection and virtually rule out bacteria. These patients need neither further testing nor antibiotics.
The (1) absence of symptoms suggesting viral infection, plus (2) the presence of fever, (3) tonsillar enlargement with exudates and (4) tender anterior cervical lymphadenopathy are criteria that suggest a bacterial etiology. Patients with all four of these criteria may reasonably be treated with antibiotics empirically. The case for empiric antibiotics is made even stronger in the symptomatic parent of a child who recently has had documented streptococcal pharyngitis.
In patients with two or three of these criteria, further testing is recommended:
Culture is still the gold standard of diagnostic methods. It has a sensitivity of 90 to 95%. Two problems exist with this method. First, it can delay the initiation of therapy as 24 to 48 hours of incubation are required before a result is known. Fortunately, treatment can be delayed safely for up to nine days after onset of symptoms and still be effective in preventing sequellae. Second, it can be falsely positive in that it does not differentiate between streptococcal carrier state and infection. A streptococcal carrier may have a viral pharyngitis just as easily as a non-carrier. The asymptomatic carrier state is not an indication for antibiotics.
The Rapid Antigen Detection Test (RADT) has a sensitivity between 80 to 90% and is nearly 100% specific. This means that if it is positive, the patient probably has the disease. It is also less likely than culture to pick up carriers, but more likely to miss true cases (less sensitive). In adults, sequellae from untreated streptococcal infections are so rare that a 10% false negativity rate is an acceptable risk. Therefore, in adults with only two or three clinical criteria for streptococcal infection whose RADT is negative, treatment is not recommended. The greatest advantage of RADT is that results come back almost immediately, so that patients may be tested and treatment instituted all while the patient waits in your office. RADT is more expensive than culture, however.
Children who have a higher risk of sequellae and who have a negative RADT, should also have a throat culture in case the RADT was falsely negative. If the culture is positive, they should be treated with antibiotics. Again, treatment may be safely withheld until the culture result comes back.
Adults with zero, or only one of the clinical criteria should not be tested or treated.
Figure 1, above, presents a flow chart to aid in determining who should be treated.
Antibiotic choice. Penicillin, ampicillin, or amoxicillin are the recommended treatment for streptococcal pharyngitis. (See References at the end.) Erythromycin or cephalexin are the recommended choices for those who are penicillin-allergic. Although also effective, amoxicillin/clavulenate (Augmentin), clarithromycin, azithromycin, higher generation oral cephalosporins and fluoroquinolones are not acceptable because of their broader spectrum of activity which applies selective pressure on normal flora to develop resistant mutations. These drugs, which are also more expensive, have no efficacy advantage over the recommended drugs.
It should be noted that the FDA approves a drug for treatment of a certain infection because it is proven efficacious by clinical studies. Many of the more expensive broad spectrum antibiotics have been approved for treating streptococcal pharyngitis, but authoritative organizations, such as the Infectious Disease Society of America, do not support their use.
Duration of therapy with oral antibiotics is ten days. A single intramuscular dose of benzathene penicillin may also suffice. Doses of these antibiotics are given in Table 1, below.
Conclusion. More overuse and misuse of antibiotics occurs in the management of pharyngitis than any other diagnosis. This increases the cost of healthcare through the cost of antibiotics unnecessarily prescribed and through the increased cost of treating multi-drug resistant bacterial infections created by antibiotic overuse. The implementation of antibiotics in treatment of pharyngitis can be limited to those who will truly benefit from them by following the diagnostic algorithm and taking the time to do the necessary tests when appropriate.
There must be discipline among physicians and education of patients to employ antimicrobials only when needed and curb the overuse of these potent drugs.
Article written by Gary R. Skankey, MD, FACP, Infectious Disease, Las Vegas, NV
References:
1. Cooper,
RJ, Hoffman, JR,
2. Snow, V,
Mottur-Pilson, C, Cooper, RJ, Hoffman, JR. Principles
of appropriate antibiotic use for acute pharyngitis
in adults. Ann Intern Med 2001; 134:506.
3. Linder,
JA,
4.
5.
Uptodate.com article on “Approach to Acute Pharyngitis
in Adults” by John G. Bartlett, MD
Federal funds for public health in jeopardy
Dr. Donald S.
Kwalick, MD, MPH
Chief Health Officer
As you may be aware, President Bush has proposed cuts to public health funding for FY 2006 that would have a negative impact on local public health agencies and the communities we serve.
A proposed overall cut of $1 billion in federal discretionary health funding would disproportionately affect local health systems and could be detrimental to prevention, research and health services programs. These programs are vital components of the long-term public health strategy aimed at preventing illness before it occurs in order to truly have an impact on the human toll and monetary costs disease inflicts on our society.
Two of the
largest proposed cuts directed at the Centers for Disease Control and
Prevention (CDC) are especially troubling. The proposed cut of $130 million in
funding for bioterrorism preparedness could have a tremendous impact on our
ability to respond to a public health emergency in
Of additional concern is the proposed elimination of the $131 million Preventive Health and Health Services block grant. Elimination of this funding will hinder the ability of state and local public health agencies to offer disease prevention programs. Chronic disease is an issue that has been overlooked for far too long, but has become increasingly important as the incidence of illnesses such as diabetes, asthma, arthritis, cancer and heart disease continue to mount.
The issue of funding for public health is also of local concern. The health district continues to support restoration of state funding to support local public health initiatives and is collaborating with the Washoe County Health District and Carson City Health District to present a plan for implementing a comprehensive and coordinated chronic disease program within each organization. These "public health improvement" funds at $1.10 per capita will allow this activity to proceed and thereby improve the public's health.
Public health is at the forefront of many issues we are currently facing - whether it is the tangible threat of a bioterrorist attack or an outbreak caused by a new or emerging illness. A strong partnership of federal, state and local resources is imperative for protecting the public health of our nation and an integral component of our homeland security efforts.
Minutes Synopsis
BOARD OF TRUSTEES MEETING
Tuesday,
Minutes Synopsis
The minutes were amended to note an attendance correction and passed unanimously.
Financial Report
Dr. Steinberg reported the revenue for these seven months of the fiscal year was more year-to-date compared to last year, primarily due to membership renewals and newsletter advertising. Expenses are up compared to last year at this time.
Dr. Steinberg presented a bid from Helix Electric to replace the outside lights which had been vandalized. The Board approved this bid.
Credentials Committee
The following three physicians were approved for active membership: David T. C. Chan, MD, Family Practice; Ethan M. Cruvant, MD, Internal Medicine; and Russell T. Nevins, MD, Orthopaedic Surgery.
Membership Report
Dr. Kline reported
there were 699 dues paid members, which was an improvement over the 619 last
year at this time and represents approximately 25 percent of the physicians in
Community
Health/Community Relations Committee
Dr. Jameson reported that the committee is working to arrange a regular feature in the Las Vegas Review-Journal. The Board granted permission to send a fax to all CCMS members to gauge their interest in participating in this program. Dr. Jameson also reported the committee is working to develop a web-based list of potential avenues for volunteer opportunities.
Nominating Committee
Report
A copy of the Nominating Slate was presented for review.
Delegation Committee
Dr. Chowdhry made a call for delegates. This year's meeting is
being held in
CCMS
The
Health District
Report
Dr. Kwalick submitted a written report.
UNSOM Report
Dr. Lenhart reported that the governor included funding to grow
residencies and fellowships by 17 in this biennium and 34 in the next biennium,
which will allow us to grow these programs -
Scholarship Report
Dr. Ellerton reported that the Board of Directors of the Scholarship Fund mapped out a plan for the 2005-2006 year. There will be four $1,000 scholarships given to students through five programs. Additionally, there will be a $1,000 award to a graduating pediatrics student in honor of Dr. Linda Golden. The Board agreed to invite scholarship recipients to the CCMS Installation Dinner.
NSMA Report
Dr. Evins reported the Legislative Core Group meets at the CCMS
office every Thursday at
President's Report
Dr. Colletti informed the Board that he had a member request an electronic format of the CCMS database. The Board reaffirmed the Society's policy of disallowing distribution of the database electronically without specific authorization of the Board.
New Business
After a brief discussion, Dr. Zamboni was nominated for the NSMA Distinguished Physician Award.
The next
meeting will be on
There being
no further business, the meeting was adjourned at
Referral Tallies
Referrals to CCMS
members
Specialty Referrals
Addiction Medicine 0
Allergy 3
Anesthesiology 0
Cardiology 4
Cardiovascular Surgery 1
Dermatology 12
Diagnostic Radiology 0
Endocrinology 3
Family Practice 21
Gastroenterology 6
General Surgery 6
Geriatrics 6
Gynecologic Oncology 0
Hematology 1
Infectious Medicine 0
Internal Medicine 34
Nephrology 0
Neurology 5
Neurosurgery 0
Ob-Gyn 17
Oncology 9
Ophthalmology 12
Oral/Maxillofacial Surg. 0
Orthopaedic Surgery 13
Otolaryngology 6
Pain Mgmt/Medicine 5
Pathology 0
Pediatrics 2
Physical Med/Rehab 5
Plastic Surgery 13
Psychiatry 8
Pulmonology 5
Radiology 1
Rheumatology 4
Thoracic Surgery 1
Urology 10
Vascular Surgery 3
Totals
219
Classifieds
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· UPSCALE PROFESSIONAL OFFICE SPACE Excellent location at 215/Pecos. New, one story, 1000-2000 sq. ft. Build to suit. Completion end of April. Call Jill at 702-310-8468.
· PHYSICIAN WANTED: INTERNAL MEDICINE. Take charge of your career with IPC - The Hospitalist Company. We are searching for multi-talented individuals ready to take on a lead decision making role in hospital-based care. Contact John Barragan at 304-2144. www.hospitalist.com.
·
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1100 sq ft, 3-exam rooms/lab/Drs. Office, large check in/out. Fully furnished.
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IN
CME CALENDAR
4/27 - “Contemporary Health Law Ethics,”
5/28 - “The Physician as an Expert Witness,”
6/25 - “Contemporary Health Law Ethics,”
MLAN
364-4962
4/2 - “Risk Management & Ethics Program,”
Pri-Med Institute (877) 4PRI-MED
5/20-21 - “Pri-Med Updates,” up to 16.25 CME hours,
FREE to CCMS members, for details or to register visit www.pri-med.com/updates/lasvegas
4/9 - “Weapons of Mass Destruction”
4/18 - “Weapons of Mass Destruction”
5/7 - “Weapons of Mass Destruction”
5/19 - “Weapons of Mass Destruction”
Southwest Medical
Associates 242-7735
4/14 - “GI Malignancies: Screening and Surveillance”
4/5 - “Should That Patient Die? The Ethics of Liver
Transplantation,”
4/8-9 - “8th Annual Acute Care Symposium: The Pediatric Hospitalist Conference,” 12 CME hours (697-5234)
4/12 - “Cultural Diversity: Meeting the Needs of the African
American Patient,”
4/13 - “Medical Ethics,”
4/19 - “Child Abuse: Burns,”
4/25 - “Hepatitis C,”
UMC 383-2604
4/9 - “Weapons of Mass Destruction & Ethical Issues,”
4/12 - “What You Should Know about
4/26 - “Vertebral Axial Decompression & Pulsed
Radiofrequency: Two Safe and Effective Treatments for Low Back and Neck Pain
(Ethics),”
5/10 - “Radiation Hazards,”
5/24 - “Use of ARBs in Control of
Hypertension,”
To have your CME
courses listed on our calendar, contact Deborah Barton
at 739-9989 prior to the 12th each month.
Clark County Health District Disease Statistics* - February 2005
DISEASE CASES REPORTED YEAR
TO DATE
Feb 2004 Feb 2005 2004 2005
VACCINE PREVENTABLE DISEASES
DIPTHERIA 0 0 0 0
HAEMOPHILUS
INFLUENZA 0 3 0 4
(invasive)
HEPATITIS A 1 1 1 1
HEPATITIS B 4 1 7 3
INFLUENZA 2 64 51 86
MEASLES 0 0 0 0
MUMPS 0 0 0 0
PERTUSSIS 0 1 0 3
POLIOMYELITIS 0 0 0 0
RUBELLA 0 0 0 0
TETANUS 0 0 0 0
SEXUALLY TRANSMITTED DISEASES**
CHLAMYDIA 295 447 653 900
GONORRHEA 155 207 349 427
SYPHILIS
(Early Latent) 0 0 1 0
SYPHILIS
(Primary & Secondary)0 5 2 8
ENTERICS
AMEBIASIS 2 0 3 2
BOTULISM-INTESTINAL
0 0 0 0
(INFANT)
CAMPYLOBACTERIOSIS 1 13 3 17
CHOLERA 0 0 0 0
CRYPTOSPORIDIOSIS 0 0 1 2
E. COLI
O157:H7 1 0 3 0
GIARDIA 9 4 12 6
ROTAVIRUS 170 51 326 135
SALMONELLOSIS 2 2 14 16
SHIGELLOSIS 6 13 11 17
TYPHOID
FEVER 0 0 0 0
VIBRIO 0 0 0 0
YERSINIOSIS 0 0 0 0
OTHER
ANTHRAX 0 0 0 0
BOTULISM
INTOXICATION 0 0 0 0
BRUCELLOSIS 0 0 0 0
COCCIDIOIDOMYCOSIS 8 8 13 15
ENCEPHALITIS 0 0 0 1
HANTAVIRUS 0 0 0 0
HEMOLYTIC
UREMIC 0 0 0 0
SYNDROME(HUS)
HEPATITIS C 1 0 1 0
HEPATITIS D 0 0 0 0
LEGIONELLOSIS 0 3 1 3
LEPROSY 0 0 0 0
LEPTOSPIROSIS 0 0 0 0
LISTERIOSIS 0 0 0 0
LYME
DISEASE 0 0 0 0
MALARIA 0 0 1 0
MENINGITIS,
ASEPTIC/VIRAL 4 1 8 5
MENINGITIS,
BACTERIAL 2 0 4 3
MENINGOCOCCAL
DISEASE 0 2 2 2
PLAGUE 0 0 0 0
PSITTACOSIS 0 0 0 0
Q FEVER 0 0 0 0
RABIES
(HUMAN) 0 0 0 0
RELAPSING
FEVER 0 0 0 0
ROCKY MTN
SPOTTED FEVER 0 0 0 0
RSV 442 449 723 881
TOXIC SHOCK
SYNDROME 1 0 1 1
TOXIC SHOCK
SYN 1 0 2 1
(STREPTOCOCCAL)
TUBERCULOSIS 9 5 16 12
TULAREMIA 0 0 0 0
UNUSUAL
ILLNESS 0 0 0 0
(ENCEPHALITIS)
*Numbers include confirmed and probable cases.
**For
HIV/AIDS statistics please call the Clark County Health District Office of AIDS
@ 759-0730.
County Line
Bank of Commerce ….. 949-9800 ….. www.bankofcommerce-nevada.com
Business Funding Solutions ….. 248-3016 ….. www.businessfundingsolutions.net
Colonial Bank ….. 304-3770 ….. www.colonialbank.com
DMSL Medical Management & Billing Service ….. 558-2326
Hutchison & Steffen Attorneys ….. 385-2500 ….. www.hsnvlaw.com
Investment Equity ….. 547-1110 ….. www.investmentequity.com
Medical Group Management Association ….. 697-5471 ext. 134
Medical Liability Association of
Nevada First Bank ….. 310-4000 ….. www.nevadafirstbank.com
Nevada Mutual Insurance Company ….. 798-6001 ….. www.nevadamutual.com
Matthew Passalacqua, Financial Advisor ….. 254-1263 ….. www.tricorfinancialservices.com
Priority One Commercial ….. 228-7464 ….. www.priorityonecommercial.com
Protrans ….. 877-6333 ….. www.protranslv.com
Red Rock Radiology ….. 731-2888 ….. www.redrockradiology.com