Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

Volume 105, Issue 6 (September 2006)

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John J. Frey, MD, Medical Editor, Wisconsin Medical Journal
Wisconsin’s health disparities challenge physicians
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Two articles in this issue of the Wisconsin Medical Journal bring particular attention to the health issues that arise from our increasingly diverse Wisconsin population. Carty and her colleagues look at health disparities in the state over the last decade of the 20th century (p 26) and McLean and colleagues address one particular, but devastating, cancer that exemplifies both the diagnostic and therapeutic dilemmas associated with it as they relate to race and gender (p 32).


Sanjay K. Shukla, PhD
CA-MRSA triangulation: Virulent strains, susceptible hosts, and contaminated environments
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Thanks to the innate genomic plasticity of microbial pathogens, the introduction of new risk factors, the availability of susceptible hosts, and discovery of novel pathogens, new or reemerging infectious diseases are recognized every few years. The last 3 decades have witnessed several such examples, from relatively uncommon granulocytic ehrlichiosis to Lyme disease to pandemic acquired immunodeficiency disease to the reemergence of tuberculosis worldwide. Some infectious diseases grow into epidemic or pandemic proportions, while others are largely restricted to a geographical region or become cyclical.

Lee Vermeulen, RPh, MS
Medication costs in Wisconsin Medicaid: Waste not, want not?
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In this issue of the Wisconsin Medical Journal, Mergener and Carr present the results of a quasi-experimental trial measuring the impact of an educational intervention on the prescribing behavior of clinicians caring for Medicaid beneficiaries. At the time of the study, the Wisconsin Medicaid program had total expenses for medications approaching $800 million per year, and the cost of the anti-epileptic medications targeted in this study were nearly 5% of those expenditures. The investigators used a relatively simple intervention consisting of mailing high-volume prescribers information summarizing the evidence surrounding the use of targeted medications, along with a list of their patients who were receiving those products. Using data available through the Medicaid program, the investigators were able to limit their intervention to only those patients who were receiving the targeted medications for “off-label” (non-FDA approved) indications, where the evidence supporting safety and efficacy was weakest.

Bradley L. Manning, Jr, MD
Wisconsin Medical Society embarks on campaign to define high-quality care
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We know the health system needs to change in order to provide patients the highest-quality care. As physicians, we need to do our part. That means acknowledging and adhering to proven best practices, and not relying primarily on anecdotal experience to guide our decision-making.

Original Research

Michael A Mergener, RPh, PhD; Richard M. Carr, MD, MS
Analysis of Anti-Epileptic Drugs in Fee-For-Service Wisconsin Medicaid
(full text PDF)

Introduction: Off-label use of prescription drugs presents issues of patient safety and can significantly increase the overall prescription drug expenditure in providing health care services. As a class, the anti-epileptic drugs are provided for off-label use on a frequent basis. Because of the safety issues and increased cost with such prescribing practices, the Wisconsin Medicaid Drug Utilization Review Board (DUR board) reviewed the use of anti-epileptic agents in the fee-for-service Wisconsin Medicaid population.

Methods: Prescribers with the highest amount paid for drugs in this class, and for which there was no appropriate diagnosis (intervention group), were provided with a list of the patients for whom they prescribed the drug for an off-label clinical condition. A total of 488 prescribers were contacted and informed of the costs and hazards of off-label prescribing.

Results: Using a comparison group of patients who were prescribed anti-epileptic agents but who did not reach the amount paid threshold (non-intervention group), the study demonstrated a decrease of 6652 prescriptions in the intervention group and an increase of 4194 in the non-intervention group. In addition, expenditures for the intervention group dropped by $752,232 and the non-intervention group rose by $835,351. It is estimated that the overall financial impact of this intervention was a savings of $2,552,077 over the 5-month period of review.

Denise C. Carty, MA, MS; Wen-Jan Tuan, MS; Gloria Johnson-Powell, MD
Monitoring Racial/Ethnic Mortality Disparities in Wisconsin: 1991-2000
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Background: Wisconsin has a goal to eliminate health disparities by 2010, but there is no consistent standard used to evaluate progress. Methodological debates persist regarding using individual group change or relative comparisons to monitor disparities.

Objectives: To examine mortality disparities among racial/ethnic populations in Wisconsin using statistically significant changes in individual population mortality rates and rate ratios as measures of disparity. These measures are proposed to monitor and evaluate progress in eliminating racial/ethnic health disparities.

Methods: The Wisconsin Interactive Statistics on Health database was queried to obtain Wisconsin all-cause mortality data by race and age for the 1991-1995 and 1996-2000 periods. Age-specific and age-adjusted rates were compared across 5 major racial/ethnic populations in Wisconsin.

Results: Age-adjusted mortality generally declined for all racial/ethnic populations in Wisconsin from 1991-1995 to 1996-2000. However, disparities increased significantly for African American infants, African Americans 45-64 years old, and Hispanics/Latinos 25-44 years old. Using non-Hispanic whites as a referent resulted in a paradoxical increase in disparities for Hispanics/Latinos despite a significant reduction in mortality in this group.

Conclusion: A statistically significant percent change in mortality rates and rate ratios is a useful standard to monitor health disparities and foster communication and targeted action around Wisconsin’s goal to eliminate racial/ethnic health disparities.

Ashly McLean, BS; Warren LeMay, DDS, MPH; Peter Vila, BS; Mark Wegner, MD, MPH; Patrick Remington, MD, MPH
Disparities in Oral and Pharyngeal Cancer Incidence and Mortality Among Wisconsin Residents, 1999-2002
(full text PDF)

Objective: Compare incidence, mortality, and trends of oral cancer (including the pharynx) in Wisconsin and the United States by race and gender from 1999-2002.

Methods: Age-adjusted incidence rates were compared using data from the Centers for Disease Control and Prevention (CDC WONDER). Mortality rates were compared using data from the Wisconsin Interactive Statistics on Health (WISH) and CDC US Cancer Statistics.

Results: Incidence rates for oral cancer were higher among males than females in both Wisconsin and the United States. Trends in the incidence rate show the gender disparity has not changed. Furthermore, the incidence rate for African American males is higher in Wisconsin than in the United States. Mortality rates for males were approximately 2 times higher than females in Wisconsin and the United States. Additionally, African American males are more likely than white males to die from this form of cancer, and the likelihood is higher in Wisconsin than in the United States (2.4 versus 1.8, respectively).

Conclusion: Racial disparities in oral cancer for African American males are greater in Wisconsin than in the United States. This may result from variation in access to oral health care, tobacco and alcohol use, as well as limited resources in detection and prevention methods. Wisconsin should focus its oral cancer prevention activities on this high-risk group.

Richard A. Proctor, MD
Community Acquired Methicillin Resistant Staphylococcus aureus: A Wisconsin Perspective
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Community-acquired methicillin-resistant Staphylo-coccus aureus have swept across the United States, causing severe morbidity and mortality (see Table 1). This manuscript provides some illustrative cases seen in Wisconsin.

Kristen H. Reynolds, MD; Sarah E. Halsmer, BS
Injuries from Ultimate Frisbee
(full text PDF)

Objective: This paper will explore ultimate frisbee injuries.

Method: This study uses an anonymous, retrospective, self-reported survey of 135 adult athletes at a Midwestern ultimate frisbee tournament. Subjects were queried regarding injuries to specific body parts, those causing missed activity, recurring injuries, medical care sought, basic demographic data, duration of participation, handedness, and eye color. Categorical data were analyzed by chi-square tests. Qualitative responses were categorized by themes. Results: Respondents had a mean age of 28 years and 59% were male. Mean playing time was 8.2 hours per week and 7.5 total years. Ultimate frisbee injuries included muscle strains (76% of subjects), ankle (65%), knee (53%), shoulder (37%), head (30%), and rib (21%) injuries. Blisters/calluses and black toenails were frequently mentioned. Recurrent injuries were reported in 49%. Shoulder injuries were more common in men than women (47% versus 24%, P<0.02). Of respondents, 88% have missed ultimate frisbee activity due to injury, and 71% have sought medical care for ultimate frisbee injuries. Conclusions: The majority of surveyed ultimate frisbee players experience injuries and seek medical care. Health care professionals should be aware of the injuries associated with ultimate frisbee and further studies should focus on prevention and education strategies. Rachael A. Wyman, MD; Jon G. Keevil, MD; Kjersten L. Busse, RN, MSN; Susan E. Aeschlimann, RDMS, RVT; Claudia E. Korcarz, DVM, RDCS; James H. Stein, MD
Is the Ankle-Brachial Index a Useful Screening Test for Subclinical Atherosclerosis in Asymptomatic, Middle-Aged Adults?
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Background: Measurement of the ankle-brachial index (ABI) is recommended as a screening test for cardiovascular risk prediction in individuals ?50 years old; however, there is little data regarding the utility of the ABI as a screening test in individuals for whom physicians actually order non-invasive testing for cardiovascular risk prediction.

Methods: This study included 493 consecutive asymptomatic patients without known atherosclerotic vascular disease who were referred by their physician for measurement of the ABI and ultrasound measurement of carotid intima-media thickness (CIMT). ABI values were classified as “reduced” (<0.9), “normal” (0.9-1.3), and “increased” (>1.3).

Results: The mean age of the patients was 55.3 (standard deviation 7.5) years. Only 1 patient had a reduced ABI (0.2%). ABI values tended to be higher in those with increased CIMT (P=0.051); however, CIMT was not significantly different between those with normal and increased ABI values (P=0.802). There were no significant differences in the prevalence of traditional cardiovascular risk factors or carotid plaque presence among the ABI groups.

Conclusions: Despite recommendations, the ABI is not sensitive as a screening tool for detecting subclinical atherosclerosis in asymptomatic middle-aged individuals.

Case Reports

Joseph Bachir, MD, FRCS; Geri L. Fitch, RN, MA, C-FNP
Northern Wisconsin Married Couple Infected with Blastomycosis
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Blastomycosis is an uncommon, chronic, granulomatous disease caused by the dimorphic fungus Blastomycosis dermatitidis. The great majority of infections start with primary pulmonary involvement through inhalation of spores. Hematogenous dissemination to other sites occurs in 25% to 30% of cases. The most common secondary site is the skin, followed in order by bone, genitourinary system, and central venous system. We report 2 cases of blastomycosis originating in a husband and wife who were both symptomatic and diagnosed with blastomycosis within 4 months of each other. One presented with pulmonary symptoms, the other with cutaneous symptoms. These 2 cases of husband and wife are of interest not only because of their rarity but also because of the potential mode of transmission.

Letter to the Editor

Sara Finger
Further need for EC awareness and access
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On behalf of the Compassionate Care for Rape Victims Coalition (CCRV), a diverse group of organizations dedicated to ensuring comprehensive health care for rape victims, I wish to further address the issues raised in the recently published paper titled “Emergency Contraception in Wisconsin: A Review.” (WMJ. 2006;105(5):40.)

Your Practice

Lindsey Bennett, MD; Robert Crouse, MD; David Feldstein, MD
Clinical Use of Evidence-Based Medicine– Clinical Questions:
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Clinical Question In a patient with idiopathic pulmonary fibrosis, does N-acetylcysteine decrease dyspnea or mortality?

Jay A. Gold, MD, JD, MPH; Kristi Michalowski, MS, CPHQ
MetaStar’s Health Care and Culture project: Does your clinic meet federal standards?
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Did you know that the US Department of Health and Human Services (HHS) has advised health care professionals receiving federal financial assistance (excluding providers that receive only Medicare Part B payments) that they may violate the Civil Rights Act if they fail to take reasonable steps to provide those who aren’t fluent in English a meaningful opportunity to participate in their programs?

Sean Cote
Want to retire early? How to avoid the 10% penalty
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Many people dream of retiring early or reducing their work hours prior to retirement. If you hope to retire before age 59½, you need to be aware that the Internal Revenue Service imposes a stiff penalty for withdrawing money early from your retirement savings.

Your Profession

Robert N. Golden, MD
Advancing the Wisconsin Idea
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It is a great honor and privilege to serve as the ninth dean of the University of Wisconsin School of Medicine and Public Health (SMPH), 1 of the state’s 2 outstanding medical schools. I welcome this opportunity to initiate on-going communication with members of the Wisconsin Medical Society through the Wisconsin Medical Journal. Congratulations to the new editor, John Frey, MD, former chair of the SMPH Department of Family Medicine. I first met John years ago at the University of North Carolina at Chapel Hill (UNC-CH), where I spent the last 2 decades, and I’m proud to have followed in his footsteps to Wisconsin.

Paul M. Grossberg, MD
An evidence-based context to address health care for gay and lesbian patients
(full text PDF)

The Wisconsin Medical So-ciety mission is to “improve the health of the people of Wisconsin by supporting and strengthening physicians’ ability to practice high quality patient care in a changing environment.” Indeed, changes in health care delivery and increased attention to health disparities in our patient populations challenge us to provide the highest quality of care to all of our patients, including gay, lesbian, bisexual, and transgender patients and their families.

Paul A. Wertsch, MD
Proposed constitutional amendment means restrictions of health care access
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This November, the following constitutional amendment defining marriage will be on the ballot: “Only a marriage between one man and one woman shall be valid or recognized as a marriage in this state. A legal status identical or substantially similar to that of marriage for unmarried individuals shall not be valid or recognized in this state.” As physicians, we must oppose this amendment—regardless of your feelings about gay marriage, or homosexuality in general. The problem lies in the second sentence. Unintended consequences have caused considerable turmoil in other states that have passed constitutional amendments with similar verbiage. If followed to the letter, many men, women and children could lose their access to health care, something which, as physicians, we cannot allow.

Your Society

Wisconsin Medical Society
Nominating Committee solicits nominees
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The House of Delegates Nominating Committee is requesting nominations for the following Society offices: