Assessment of postgraduate skin lesion education among Iowa family physicians.

BACKGROUND: Family medicine physicians play a pivotal role in the prevention and early detection of skin cancer. Our objective was to evaluate how family physicians believe their postgraduate training in skin cancer screening and prevention has prepared them for independent practice and to assess the need for enhanced skin lesion teaching in a family medicine residency setting. METHODS: A descriptive, cross-sectional survey investigating provider demographics, confidence in providing dermatological care, residency training, current medical practice, and skin cancer prevention beliefs was mailed to all family medicine physicians in the state of Iowa as listed in the Iowa Academy of Family Physicians annual directory in 2006 (N = 1069). RESULTS: A total of 575 family medicine physicians completed the survey for an overall response rate of 53.8%. Overall, family medicine physicians reported feeling confident in their ability to diagnose skin lesions (83.2%), differentiate between benign and malignant lesions (85.3%), and perform a biopsy of a lesion (94.3%). Only 65% of surveyed physicians felt that their residency program adequately trained them in diagnosing skin lesions and 65.7% of physicians agree that they could have benefited from additional training on skin lesions during residency training. Nearly 90% of clinicians surveyed believe that skin cancer screenings are the standard of care; however, only 51.8% perform skin cancer screening examinations during adult health maintenance visits more than 75% of the time. The primary reason listed by respondents who said they do not routinely perform skin cancer screenings was inadequate time (68.2%). CONCLUSION: Family medicine physicians in the state of Iowa are confident in evaluating skin lesions. However, they reported a need for additional enhanced, targeted skin lesion education in family medicine residency training programs. Physicians believe that skin cancer screening examination is the standard of care, but find that inadequate time increasingly hinders skin cancer screening during routine health maintenance examinations.

An open-label, pragmatic, randomized controlled clinical trial to evaluate the comparative effectiveness of daptomycin versus vancomycin for the treatment of complicated skin and skin structure infection.

BACKGROUND: Treatment of complicated skin and skin structure infection (cSSSI) places a tremendous burden on the health care system. Understanding relative resource utilization associated with different antimicrobials is important for decision making by patients, health care providers, and payers. METHODS: The authors conducted an open-label, pragmatic, randomized (1:1) clinical study (N = 250) to compare the effectiveness of daptomycin with that of vancomycin for treatment of patients hospitalized with cSSSI caused by suspected or documented methicillin-resistant Staphylococcus aureus infection. The primary study end point was infection-related length of stay (IRLOS). Secondary end points included health care resource utilization, cost, clinical response, and patient-reported outcomes. Patient assessments were performed daily until the end of antibiotic therapy or until hospital discharge, and at 14 days and 30 days after discharge. RESULTS: No difference was found for IRLOS, total LOS, and total inpatient cost between cohorts. Hospital LOS contributed 85.9% to the total hospitalization cost, compared with 6.4% for drug costs. Daptomycin showed a nonsignificant trend toward a higher clinical success rate, compared with vancomycin, at treatment days 2 and 3. In the multivariate analyses, vancomycin was associated with a lower likelihood of day 2 clinical success (odds ratio [OR] = 0.498, 95% confidence interval [CI], 0.249-0.997; P < 0.05). CONCLUSION: This study did not provide conclusive evidence of the superiority of one treatment over the other in terms of clinical, economic, or patient outcomes. The data suggest that physician and patient preference, rather than drug acquisition cost, should be the primary driver of initial antibiotic selection for hospitalized patients with cSSSI. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01419184 (Date: August 16, 2011).

Adherence to clinical practice guidelines for 7 chronic conditions in long-term-care patients who received pharmacist disease management services versus traditional drug regimen review.

BACKGROUND: Numerous studies have shown that adherence to published clinical practice guidelines (CPGs) reduces disease morbidity and mortality. However, few benchmarks exist that demonstrate the rate of adherence to CPGs in patients in long-term-care facilities (LTCFs). OBJECTIVE: To evaluate CPG adherence in patients in LTCFs who received consultation from pharmacists who emphasize disease state management (DSM) compared with patients in other LTCFs who received traditional drug regimen review (DRR). METHODS: A retrospective chart review was conducted in November 2005 for 107 patients who received DSM services in 2 LTCFs and 304 patients who received DRR services in 4 LTCFs for the service period ending September 30, 2005. Chart review was conducted on all patients included in the current census as of September 1, 2005; residents were excluded from the analysis if they were discharged or deceased between September 1, 2005, and the date of chart review. CPG adherence was evaluated for the following 7 conditions: diabetes, coronary artery disease (CAD), stroke, heart failure (HF), hypertension, hyperlipidemia, and osteoporosis. In addition, the 6 most recent pharmacist recommendations for each patient were classified according to disease state. RESULTS: Adherence to CPGs was significantly better (all P <0.05) in patients receiving DSM services for the following performance measures for 4 of the 7 disease states: (1) diabetes: antiplatelet or warfarin use or contraindication for use (hypersensitivity or history of serious bleeding event), 89.7% for DSM services versus 71.0% for DRR services, and glycosylated hemoglobin (HbA1c) 0.05). The mean number of pharmacist recommendations per patient per month was greater in DSM facilities (0.76) compared with DRR facilities (0.23, P <0.001). Pharmacists who provided DSM consultant services were more likely to make a recommendation to improve DSM (51.6%) than were pharmacists in the comparison facilities who provided traditional DRR services (31.7%, P <0.001). CONCLUSION: This self-evaluation of the provision of pharmacist consultant services that focus on disease management in addition to DRR found a higher rate of adherence to clinical practice guidelines for 4 of 7 common chronic disease states in long-term-care patients compared with patients who received only traditional DRR services.

Oral antivirals for the acute treatment of recurrent herpes labialis.

OBJECTIVE: To evaluate the use and benefit of oral antivirals in the acute treatment of episodic, recurrent herpes labialis. DATA SOURCES: A literature search was performed in MEDLINE (1966-August 2003) using acyclovir, famciclovir, valacyclovir, cold sores, herpes labialis, and HSV-1 as search terms. DATA SYNTHESIS: We reviewed 5 placebo-controlled and 2 comparative studies evaluating oral antivirals for acute treatment of recurrent herpes labialis. No studies directly compared different antivirals. Studies discussing the efficacy of antivirals for chronic suppression of herpes simplex virus-1 infection were not included. CONCLUSIONS: Treatment with oral antivirals decreases the duration of lesion episodes and pain by approximately one day; however, the antivirals do not abort lesions from developing. Clinical implications of these results appear relatively modest.

Achieving the best outcome in treatment of depression.

Combined treatment with psychotherapy or psychiatric consult and drug therapy has shown better response in several studies than either therapy alone. Although not proven by clinical trials, selecting a medication by matching its side-effect profile to patient characteristics is supported by case reports and likely enhances compliance. Patients who do not improve with initial therapy often benefit from being switched to another class of antidepressants, or having a drug from another class added to their therapy.