Joyce Frieden

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates.

And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Software systems could have a mechanism, such as the one above, to alert prescribers to potentially fatal allergies and drug-drug interactions. Courtesy Dr. David Bates

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates.

And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Software systems could have a mechanism, such as the one above, to alert prescribers to potentially fatal allergies and drug-drug interactions. Courtesy Dr. David Bates

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates.

And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Software systems could have a mechanism, such as the one above, to alert prescribers to potentially fatal allergies and drug-drug interactions. Courtesy Dr. David Bates

BALTIMORE — There might not have been thunderous applause at last month's meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

“I'm pleased by the opportunity to have all the evidence considered,” he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package.

Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group.

In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

He noted that the primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

“We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. “They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%.”

He noted that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

Many insurers pay for statins even though patients go off the drugs after a few months, Dr. Dean Ornish noted at the meeting. Vivian E. Lee

BALTIMORE — There might not have been thunderous applause at last month's meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

“I'm pleased by the opportunity to have all the evidence considered,” he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package.

Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group.

In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

He noted that the primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

“We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. “They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%.”

He noted that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

Many insurers pay for statins even though patients go off the drugs after a few months, Dr. Dean Ornish noted at the meeting. Vivian E. Lee

BALTIMORE — There might not have been thunderous applause at last month's meeting of the Medicare Coverage Advisory Committee, but the quiet approval was quite enough for Dean Ornish, M.D.

The committee, which advises Medicare on coverage issues, voted to recommend that Medicare cover the use of physician-supervised intensive diet and lifestyle change programs for preventing and reversing heart disease—programs such as the one developed by Dr. Ornish.

“I'm pleased by the opportunity to have all the evidence considered,” he said after the panel approved the recommendation, adding that he hoped that the evidence was compelling enough for Medicare to make this type of lifestyle intervention a part of its benefits package.

Medicare is not obligated to accept the recommendation of its advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group.

In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls. Although no patients in the intervention group had had a recent cardiac event, 55% had had a prior myocardial infarction, compared with 28% of controls.

The researchers found that after 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

He noted that the primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results.

Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions.

“We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002.

More than 400 patients, average age 56, have participated, with a 90% completion rate, Mr. Lambert said. “They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%.”

He noted that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

Many insurers pay for statins even though patients go off the drugs after a few months, Dr. Dean Ornish noted at the meeting. Vivian E. Lee

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

By contrast, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

By contrast, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts.

By contrast, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

BALTIMORE — Physician-supervised intensive diet and lifestyle change programs for secondary prevention of cardiovascular disease have gained the endorsement of the Medicare Coverage Advisory Committee.

The committee voted to recommend that Medicare cover such programs in patients with documented cardiovascular disease, including the program developed by Dean Ornish, M.D. “I'm pleased by the opportunity to have all the evidence considered,” he said.

Medicare is not obliged to accept the recommendation of the advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls.

After 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

The primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results. Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions. “We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002. More than 400 patients, average age 56, have participated, with a 90% completion rate, he said.

“They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%,” he said, noting that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

A CMS spokesman said there is no timetable for when a national coverage determination will be made.

Dr. Dean Ornish said Medicare should cover lifestyle interventions the same way as other heart disease treatments. Vivian E. Lee

BALTIMORE — Physician-supervised intensive diet and lifestyle change programs for secondary prevention of cardiovascular disease have gained the endorsement of the Medicare Coverage Advisory Committee.

The committee voted to recommend that Medicare cover such programs in patients with documented cardiovascular disease, including the program developed by Dean Ornish, M.D. “I'm pleased by the opportunity to have all the evidence considered,” he said.

Medicare is not obliged to accept the recommendation of the advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls.

After 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

The primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results. Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions. “We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002. More than 400 patients, average age 56, have participated, with a 90% completion rate, he said.

“They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%,” he said, noting that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

A CMS spokesman said there is no timetable for when a national coverage determination will be made.

Dr. Dean Ornish said Medicare should cover lifestyle interventions the same way as other heart disease treatments. Vivian E. Lee

BALTIMORE — Physician-supervised intensive diet and lifestyle change programs for secondary prevention of cardiovascular disease have gained the endorsement of the Medicare Coverage Advisory Committee.

The committee voted to recommend that Medicare cover such programs in patients with documented cardiovascular disease, including the program developed by Dean Ornish, M.D. “I'm pleased by the opportunity to have all the evidence considered,” he said.

Medicare is not obliged to accept the recommendation of the advisory committee.

Dr. Ornish, president of the Preventive Medicine Research Institute, Sausalito, Calif., outlined his program, which consists of putting patients on a very low-fat diet (about 10% fat), getting them on a moderate exercise program, teaching them stress management techniques such as stretching and meditation, and enrolling them in support groups.

In a 1-year study of 28 patients who took part in the program and 20 controls, he found that the average percentage diameter stenosis regressed from 40% to 37.8% in the experimental group, compared with an average progression from 42.7% to 46.1% in the control group. In addition, there was a 91% reduction in angina in the intervention group, compared with a 165% increase in the control group.

Dr. Ornish also investigated whether other providers could be trained to implement his program, so he set up demonstration projects in other sites with more than 2,000 patients.

In the first project, funded by Mutual of Omaha, the researchers studied 194 patients with angiographically documented coronary artery disease and compared them with 139 controls.

After 3 years, 77% of intervention patients who met insurance company criteria to undergo bypass or angioplasty were able to avoid it, saving Mutual of Omaha $30,000 per patient, Dr. Ornish reported.

He admitted that his program requires a lot of commitment. For the first few months, participants attend two 4-hour sessions, each consisting of exercise, meditation or other stress reduction, a support group meeting, and a lunch/lecture. Later, they decrease to once-weekly sessions, but continue for 9 months.

In a payment demonstration project for Medicare, Dr. Ornish found that patients' body weight decreased both at 12 weeks and at 1 year.

The primary determinant of how much patients improved on the program was adherence. “The more people changed, the better they got,” he said.

Advisory committee members expressed several concerns about Dr. Ornish's results. Clifford Goodman, Ph.D., a senior scientist with the Lewin Group, a Falls Church, Va., consulting firm, noted that some of the improvements in the patient groups started to reverse slightly after a year, and speculated that many patients may be self-selecting for the program at a time when their weight and other negative indicators are at their peak. “How much of the effect we're observing is simply regression to the mean?” he asked.

Dr. Ornish admitted that there was some regression but added, “there is a direct correlation between degree of adherence and outcomes at 1 year.”

Adherence was a concern for several panel members who wondered whether patients could really keep up with strict regimens such as Dr. Ornish's.

But Dr. Ornish said he was merely asking for these types of programs to be treated the same way as other interventions. “We will pay for bypass surgery and angioplasty, but diet and lifestyle interventions, Medicare generally doesn't pay for it,” he said, adding that many insurers pay for cholesterol-lowering statin drugs even though studies have shown that patients go off the drugs after a few months because they don't like the side effects.

Also testifying were spokesmen from two Blue Cross Blue Shield plans—Mountain State in West Virginia and Highmark in Pennsylvania—that pay patients to enroll in the Ornish program. Both said their plans were happy with the clinical outcomes and the cost savings.

David Lambert, vice president of health services for Mountain State Blue Cross Blue Shield, said his plan began covering the Ornish program for heart disease prevention in 2002. More than 400 patients, average age 56, have participated, with a 90% completion rate, he said.

“They collectively reduced their risk of a cardiac event by 50% as measured by the ATP Framingham risk tool, and lowered their LDL by 21%,” he said, noting that the average cost of the behavioral management program was $5,700, compared with the average cost of heart surgery, which ranges from $57,000 to $67,000. “By avoiding one procedure, it pays for 10 members to complete the program.”

The committee also heard from Alex Clark, Ph.D., of the University of Alberta's Centre for Health Evidence in Edmonton. The Centers for Medicare and Medicaid Services contracted with Dr. Clark's center to review outcomes studies for patients with symptomatic coronary artery disease undergoing one of three types of therapy: cardiac rehabilitation (group education and counseling only), comprehensive cardiac rehabilitation (such as Dr. Ornish's program, which includes exercise in addition to group education and counseling), and individual counseling. All studies had to have outcomes for at least 50 patients to be included in the review.

The reviewers found that all three types of programs had some long-term benefits, including reductions in mortality and hospitalization, and improved quality of life, Dr. Clark said. “The foundation for change is happening at 12 months.”

Information on program costs was sketchier, he noted. Only 6 out of 41 studies mentioned costs, and three of those “reported or implied” cost savings without giving any relevant data. Most of the studies were heavy on male participants, with seven studies having no women at all.

In the end, panel members generally agreed that the Ornish program and similar interventions improved patients' long-term survival rates and quality of life, but they were less certain that other providers would be able to successfully implement the program and that it could be easily translated to Medicare patients, many of whom have multiple chronic illnesses.

A CMS spokesman said there is no timetable for when a national coverage determination will be made.

Dr. Dean Ornish said Medicare should cover lifestyle interventions the same way as other heart disease treatments. Vivian E. Lee

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing a pilot pay-for-performance project, in which 10 large physician group practices will be rewarded by the agency for improving outcomes in Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn., expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these projects are limited in scope, he said during a press briefing on the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in smaller practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

“CMS will develop performance requirements and standards for Medicare administrative contractors through consultations with providers and beneficiaries, which will help ensure that the requirements produce desired results,” the agency said in a report on Medicare contracting reform submitted to Congress last month.

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing a pilot pay-for-performance project, in which 10 large physician group practices will be rewarded by the agency for improving outcomes in Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn., expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these projects are limited in scope, he said during a press briefing on the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in smaller practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

“CMS will develop performance requirements and standards for Medicare administrative contractors through consultations with providers and beneficiaries, which will help ensure that the requirements produce desired results,” the agency said in a report on Medicare contracting reform submitted to Congress last month.

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing a pilot pay-for-performance project, in which 10 large physician group practices will be rewarded by the agency for improving outcomes in Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn., expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these projects are limited in scope, he said during a press briefing on the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in smaller practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

“CMS will develop performance requirements and standards for Medicare administrative contractors through consultations with providers and beneficiaries, which will help ensure that the requirements produce desired results,” the agency said in a report on Medicare contracting reform submitted to Congress last month.

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.”

WASHINGTON — The trend toward consumer-driven health care will ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which is already consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership. The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people without health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” she noted.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well rewarded, Dr. Herzlinger continued. As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing care teams. “In 1 year, he lowered the costs by 40%,” she said.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products will be developed to respond to the needs of different consumers, she continued. And insurers will realize they can be rewarded for considering consumers' longer-term needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger said. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams will be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians will be paid based on outcomes, “and there will be long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on will be rewarded.”

One big driver behind consumer-driven health care will be aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States. The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

She took issue with the notion that consumer-driven health care plans will be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices, the sick will be very attractive kinds of entities.”

She also disputed the notion that only those who can afford high-cost plans will get the highest-quality health care. “In the car market, what is the best car in the U.S.? Toyota,” she said. “Is that the highest-cost car? Not by a long shot.”

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training's shortcoming is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. We have to be careful not to reinforce cultural stereotypes.”

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training's shortcoming is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. We have to be careful not to reinforce cultural stereotypes.”

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training's shortcoming is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. We have to be careful not to reinforce cultural stereotypes.”

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and 5 preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing systems can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some situations.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time.

This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. The system should also have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them.

One day simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Computerized systems should have a mechanism, such as the one above, to alert prescribers about potentially fatal allergies and drug-drug interactions. COURTESY DR. DAVID BATES

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and 5 preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing systems can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some situations.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time.

This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. The system should also have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them.

One day simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Computerized systems should have a mechanism, such as the one above, to alert prescribers about potentially fatal allergies and drug-drug interactions. COURTESY DR. DAVID BATES

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and 5 preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing systems can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some situations.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time.

This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. The system should also have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them.

One day simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to all the safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

Computerized systems should have a mechanism, such as the one above, to alert prescribers about potentially fatal allergies and drug-drug interactions. COURTESY DR. DAVID BATES

WASHINGTON — Black women caring for patients with Alzheimer's disease or other dementias are less likely to be depressed than their nonblack counterparts, Betsy Sleath, Ph.D., of the University of North Carolina School of Pharmacy, Chapel Hill, said at the annual meeting of the American Public Health Association.

Dr. Sleath and her associates looked at data from the National Longitudinal Caregiver Study, a survey of informal caregivers of elderly male veterans diagnosed with probable Alzheimer's or dementia. The sample included 608 caregivers with depression, of whom 11% were African Americans. Overall, African Americans constituted 16% of the entire initial sample of more than 2,000 female caregivers.

The mean age of depressed caregivers was 67; 86% had a high school diploma or less.

The researchers found that white caregivers were almost twice as likely as African Americans to have depressive symptoms. “There are different positive reasons for that. Spirituality may play a role, as well as how you perceive something as a burden—African Americans may perceive caregiving differently than whites,” Dr. Sleath said. African Americans also were less likely to be using antidepressant and antianxiety medications.

More than 80% of caregivers with depressive symptoms were not on an antidepressant medication, but the caregivers who had more physician visits in the past 6 months were more likely to be taking antidepressants, she said. “In this population, it's probably very difficult for caregivers to go get therapy.”

The researchers found that caregivers who had more social support were actually more likely to be using antidepressants. “We find that interesting. Perhaps that's because the support network is telling them, 'Maybe you need to go on an antidepressant,'” she said.

Younger caregivers were more likely to be receiving antidepressants than older caregivers, and although slightly less than half of the caregivers had health insurance that covered prescription drugs, insurance did not seem to have an effect on medication use, she said.

Limitations of the study included using a self-reported mail-in questionnaire and that it did not examine other types of depression treatment.

WASHINGTON — Black women caring for patients with Alzheimer's disease or other dementias are less likely to be depressed than their nonblack counterparts, Betsy Sleath, Ph.D., of the University of North Carolina School of Pharmacy, Chapel Hill, said at the annual meeting of the American Public Health Association.

Dr. Sleath and her associates looked at data from the National Longitudinal Caregiver Study, a survey of informal caregivers of elderly male veterans diagnosed with probable Alzheimer's or dementia. The sample included 608 caregivers with depression, of whom 11% were African Americans. Overall, African Americans constituted 16% of the entire initial sample of more than 2,000 female caregivers.

The mean age of depressed caregivers was 67; 86% had a high school diploma or less.

The researchers found that white caregivers were almost twice as likely as African Americans to have depressive symptoms. “There are different positive reasons for that. Spirituality may play a role, as well as how you perceive something as a burden—African Americans may perceive caregiving differently than whites,” Dr. Sleath said. African Americans also were less likely to be using antidepressant and antianxiety medications.

More than 80% of caregivers with depressive symptoms were not on an antidepressant medication, but the caregivers who had more physician visits in the past 6 months were more likely to be taking antidepressants, she said. “In this population, it's probably very difficult for caregivers to go get therapy.”

The researchers found that caregivers who had more social support were actually more likely to be using antidepressants. “We find that interesting. Perhaps that's because the support network is telling them, 'Maybe you need to go on an antidepressant,'” she said.

Younger caregivers were more likely to be receiving antidepressants than older caregivers, and although slightly less than half of the caregivers had health insurance that covered prescription drugs, insurance did not seem to have an effect on medication use, she said.

Limitations of the study included using a self-reported mail-in questionnaire and that it did not examine other types of depression treatment.

WASHINGTON — Black women caring for patients with Alzheimer's disease or other dementias are less likely to be depressed than their nonblack counterparts, Betsy Sleath, Ph.D., of the University of North Carolina School of Pharmacy, Chapel Hill, said at the annual meeting of the American Public Health Association.

Dr. Sleath and her associates looked at data from the National Longitudinal Caregiver Study, a survey of informal caregivers of elderly male veterans diagnosed with probable Alzheimer's or dementia. The sample included 608 caregivers with depression, of whom 11% were African Americans. Overall, African Americans constituted 16% of the entire initial sample of more than 2,000 female caregivers.

The mean age of depressed caregivers was 67; 86% had a high school diploma or less.

The researchers found that white caregivers were almost twice as likely as African Americans to have depressive symptoms. “There are different positive reasons for that. Spirituality may play a role, as well as how you perceive something as a burden—African Americans may perceive caregiving differently than whites,” Dr. Sleath said. African Americans also were less likely to be using antidepressant and antianxiety medications.

More than 80% of caregivers with depressive symptoms were not on an antidepressant medication, but the caregivers who had more physician visits in the past 6 months were more likely to be taking antidepressants, she said. “In this population, it's probably very difficult for caregivers to go get therapy.”

The researchers found that caregivers who had more social support were actually more likely to be using antidepressants. “We find that interesting. Perhaps that's because the support network is telling them, 'Maybe you need to go on an antidepressant,'” she said.

Younger caregivers were more likely to be receiving antidepressants than older caregivers, and although slightly less than half of the caregivers had health insurance that covered prescription drugs, insurance did not seem to have an effect on medication use, she said.

Limitations of the study included using a self-reported mail-in questionnaire and that it did not examine other types of depression treatment.

SCOTTSDALE, ARIZ. — Some paraphilic stalking behaviors may be associated with right-hemispheric brain dysfunction, Montgomery Brower, M.D., said at the annual meeting of the American Academy of Psychiatry and the Law.

The brain's right hemisphere deals with visual-spatial functions, and right-hemispheric dysfunction “is something that exerts its effect early because it's either developmental or an early acquired syndrome,” said Dr. Brower of Harvard Medical School, Boston.

In either case, the dysfunction “has a developmental impact which manifests itself as a developmental learning disorder,” he noted.

The most common sign of right hemispheric dysfunction is a gap between verbal and performance IQs. “A split of 15 points is considered significant,” he said.

Patients with right hemispheric-related learning disorder, for example, often have poor recall when asked to construct a diagram from memory. However, since the left side of the brain is not impaired, these patients can often do quite well in school because their verbal and remote memorization skills are quite good. “In fact, they're often hyperdeveloped in that area,” Dr. Brower added.

Another manifestation of right-hemispheric brain dysfunction is social skills deficits. “This tends to manifest with a flat affect and diminished prosody,” he said.

These patients don't understand “the nonverbal components of interpersonal communication. They will often commit faux pas in social settings. They have trouble understanding wit and irony, and often grossly misinterpret what they're seeing, and it can sometimes result in serious interpersonal conflict because they fail to appreciate the emotional impact of their behavior on the other person,” Dr. Brower explained.

At least one study has found increased prevalence and underidentification of adult psychiatric patients with this syndrome. Other studies have found that these patients “frequently collect multiple diagnoses, none of which seem to fit comfortably,” he said.

The social skills deficits can lead to frustration in interpersonal relationships and continuing pursuit of people who are not interested in them, as was the case with one 20-year-old male who was in a juvenile facility.

“He didn't have a history of mental illness, but he showed the diminished affect, prosody, and impairments of social judgent,” Dr. Brower said. This patient also showed dysmorphic facial features consistent with fetal alcohol exposure, and he had mild impairments on visual-spatial tasks in addition to a 17-point difference in verbal and performance IQ.

This patient “didn't understand why he couldn't go and resume normal relationships with the family members of the incest victims of his pedophilia,” Dr. Brower said. “He couldn't imagine the emotional impact of trying to resume a normal family relationship with them.”

In the area of stalking behavior, one case involved a male patient who had a history of making homicidal threats to female partners who had tried to break up with him; he had been the subject of a restraining order for telephone stalking of one female victim.

During serial hospitalizations, the patient engaged in recurrent, socially inappropriate unwanted pursuit of female patients and hospital staff. He would become romantically obsessed and pursue them “and had a great deal of difficulty understanding why what he was doing was inappropriate,” Dr. Brower said.

Overall, “right-hemispheric dysfunction appears to be associated with disturbances in psychosexual development, which may contribute in some cases to paraphilic sexuality and possibly related sex-offending behavior,” he concluded. “Also, specific cognitive deficits and impairments in social skills seen in right-hemispheric dysfunction may contribute to stalking and erotic fixations.

SCOTTSDALE, ARIZ. — Some paraphilic stalking behaviors may be associated with right-hemispheric brain dysfunction, Montgomery Brower, M.D., said at the annual meeting of the American Academy of Psychiatry and the Law.

The brain's right hemisphere deals with visual-spatial functions, and right-hemispheric dysfunction “is something that exerts its effect early because it's either developmental or an early acquired syndrome,” said Dr. Brower of Harvard Medical School, Boston.

In either case, the dysfunction “has a developmental impact which manifests itself as a developmental learning disorder,” he noted.

The most common sign of right hemispheric dysfunction is a gap between verbal and performance IQs. “A split of 15 points is considered significant,” he said.

Patients with right hemispheric-related learning disorder, for example, often have poor recall when asked to construct a diagram from memory. However, since the left side of the brain is not impaired, these patients can often do quite well in school because their verbal and remote memorization skills are quite good. “In fact, they're often hyperdeveloped in that area,” Dr. Brower added.

Another manifestation of right-hemispheric brain dysfunction is social skills deficits. “This tends to manifest with a flat affect and diminished prosody,” he said.

These patients don't understand “the nonverbal components of interpersonal communication. They will often commit faux pas in social settings. They have trouble understanding wit and irony, and often grossly misinterpret what they're seeing, and it can sometimes result in serious interpersonal conflict because they fail to appreciate the emotional impact of their behavior on the other person,” Dr. Brower explained.

At least one study has found increased prevalence and underidentification of adult psychiatric patients with this syndrome. Other studies have found that these patients “frequently collect multiple diagnoses, none of which seem to fit comfortably,” he said.

The social skills deficits can lead to frustration in interpersonal relationships and continuing pursuit of people who are not interested in them, as was the case with one 20-year-old male who was in a juvenile facility.

“He didn't have a history of mental illness, but he showed the diminished affect, prosody, and impairments of social judgent,” Dr. Brower said. This patient also showed dysmorphic facial features consistent with fetal alcohol exposure, and he had mild impairments on visual-spatial tasks in addition to a 17-point difference in verbal and performance IQ.

This patient “didn't understand why he couldn't go and resume normal relationships with the family members of the incest victims of his pedophilia,” Dr. Brower said. “He couldn't imagine the emotional impact of trying to resume a normal family relationship with them.”

In the area of stalking behavior, one case involved a male patient who had a history of making homicidal threats to female partners who had tried to break up with him; he had been the subject of a restraining order for telephone stalking of one female victim.

During serial hospitalizations, the patient engaged in recurrent, socially inappropriate unwanted pursuit of female patients and hospital staff. He would become romantically obsessed and pursue them “and had a great deal of difficulty understanding why what he was doing was inappropriate,” Dr. Brower said.

Overall, “right-hemispheric dysfunction appears to be associated with disturbances in psychosexual development, which may contribute in some cases to paraphilic sexuality and possibly related sex-offending behavior,” he concluded. “Also, specific cognitive deficits and impairments in social skills seen in right-hemispheric dysfunction may contribute to stalking and erotic fixations.

SCOTTSDALE, ARIZ. — Some paraphilic stalking behaviors may be associated with right-hemispheric brain dysfunction, Montgomery Brower, M.D., said at the annual meeting of the American Academy of Psychiatry and the Law.

The brain's right hemisphere deals with visual-spatial functions, and right-hemispheric dysfunction “is something that exerts its effect early because it's either developmental or an early acquired syndrome,” said Dr. Brower of Harvard Medical School, Boston.

In either case, the dysfunction “has a developmental impact which manifests itself as a developmental learning disorder,” he noted.

The most common sign of right hemispheric dysfunction is a gap between verbal and performance IQs. “A split of 15 points is considered significant,” he said.

Patients with right hemispheric-related learning disorder, for example, often have poor recall when asked to construct a diagram from memory. However, since the left side of the brain is not impaired, these patients can often do quite well in school because their verbal and remote memorization skills are quite good. “In fact, they're often hyperdeveloped in that area,” Dr. Brower added.

Another manifestation of right-hemispheric brain dysfunction is social skills deficits. “This tends to manifest with a flat affect and diminished prosody,” he said.

These patients don't understand “the nonverbal components of interpersonal communication. They will often commit faux pas in social settings. They have trouble understanding wit and irony, and often grossly misinterpret what they're seeing, and it can sometimes result in serious interpersonal conflict because they fail to appreciate the emotional impact of their behavior on the other person,” Dr. Brower explained.

At least one study has found increased prevalence and underidentification of adult psychiatric patients with this syndrome. Other studies have found that these patients “frequently collect multiple diagnoses, none of which seem to fit comfortably,” he said.

The social skills deficits can lead to frustration in interpersonal relationships and continuing pursuit of people who are not interested in them, as was the case with one 20-year-old male who was in a juvenile facility.

“He didn't have a history of mental illness, but he showed the diminished affect, prosody, and impairments of social judgent,” Dr. Brower said. This patient also showed dysmorphic facial features consistent with fetal alcohol exposure, and he had mild impairments on visual-spatial tasks in addition to a 17-point difference in verbal and performance IQ.

This patient “didn't understand why he couldn't go and resume normal relationships with the family members of the incest victims of his pedophilia,” Dr. Brower said. “He couldn't imagine the emotional impact of trying to resume a normal family relationship with them.”

In the area of stalking behavior, one case involved a male patient who had a history of making homicidal threats to female partners who had tried to break up with him; he had been the subject of a restraining order for telephone stalking of one female victim.

During serial hospitalizations, the patient engaged in recurrent, socially inappropriate unwanted pursuit of female patients and hospital staff. He would become romantically obsessed and pursue them “and had a great deal of difficulty understanding why what he was doing was inappropriate,” Dr. Brower said.

Overall, “right-hemispheric dysfunction appears to be associated with disturbances in psychosexual development, which may contribute in some cases to paraphilic sexuality and possibly related sex-offending behavior,” he concluded. “Also, specific cognitive deficits and impairments in social skills seen in right-hemispheric dysfunction may contribute to stalking and erotic fixations.