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SGIM_September 2007-Web.qxd 8/10/07 4:18 PM Page 1 Society of General Internal Medicine SGIM TO PROMOTE IMPROVED PATIENT CARE, RESEARCH, AND EDUCATION IN FORUM PRIMARY CARE AND GENERAL INTERNAL MEDICINE Volume 30 • Number 9 • September 2007 ROM THE IELD On June 6, 2007, the program “Marketplace” aired a brief commentary by F F SGIM Member Stefan Kertesz, MD, of the University of Alabama at Birmingham, asking whether increasingly aggressive standards for glucose control in the care Why So Much of diabetic patients may help to explain the enormous popularity of Avandia. At SGIM Forum’s request, Dr. Kertesz has gently expanded that radio commentary Avandia in the for the SGIM Forum audience. First Place? he downfall of The Ethics of GlaxoSmithKline’s “The challenge for primary care Tblockbuster diabetes drug Avandia (rosiglita- internists, and for our patients, is Quality zone) took its toll on Improvement morning rounds this past a rise in absolutist, binary, May. A widely publicized outcome-based quality Stefan Kertesz, MD, MSc meta-analysis, first pub- lished online by the New standards for the treatment of England Journal of Medicine, reported an each chronic medical condition.” increased risk of myocar- Contents dial infarction among per- sons receiving Avandia in comparison to minutes of notoriety. Where was the 1 From the Field other treatments [Odds Ratio (OR) 1.43, FDA? What about that marketing? These 95% Confidence Interval (CI) 1.03- questions matter, but they were not my 2 This Month in JGIM 1.98]. The same paper also suggested a question. To frame Avandia’s downfall as possible association between Avandia merely Vioxx “Part Deux” is to miss the 3 President's Column and all-cause mortality (OR 1.64, 95% point of greatest relevance to those who CI 0.98-2.74). Amid fierce media reac- are passionate about quality in the pri- 4 From the Society tion and public outrage, Avandia joined mary care of people with chronic illness. our morning rounds. Diabetes is a lethal chronic disease 5 Abstractions During visits to patients’ rooms over increasingly central to primary care, and the next few weeks, we heard televisions it has been the formidable target of 6 Ask the Expert blare: “If you think you’ve been harmed national quality initiatives for at least a by Avandia, call our attorneys.” One decade. My question, first broadcast on morning, a resident was drawn away from Public Radio International’s Marketplace, 7 Between Us the bedside of a man admitted for unsta- is “why were we prescribing so much ble angina to handle a call from a clinic Avandia in the first place?” 8 Funding Corner patient worried about Avandia. We grum- In recent years, we’ve put patients on bled about the intrusion on our time, but two or even three medications just to 9 In Training that mild inconvenience paled in com- meet the elusively low glycosylated parison to the possibility that some hemoglobin target of 7%, as endorsed by 10 From the Regions patients might have been hurt or killed by the American Diabetes Association and medicines offered with every intention of recently enshrined in the measures speci- helping them. fied by the National Committee for Editorialists quickly resurrected the Quality Assurance, although other expert same questions that had been on our lips bodies (e.g. the Veterans Health two years ago, when Vioxx enjoyed its 15 continued on page 11 SGIM_September 2007-Web.qxd 8/10/07 4:18 PM Page 2 SGIM FORUM HIS ONTH IN SOCIETY OF GENERAL INTERNAL MEDICINE T M JGIM OFFICERS Life Chaos: Impacts on Health PRESIDENT Eugene Rich, MD • Omaha, NE [email protected] • (202) 887-5150 and Health Care Utilization PRESIDENT ELECT Lisa V. Rubenstein, MD, MSPH • North Hills, CA Adam Gordon, MD, MPH [email protected] • (818) 891-7711 This month in JGIM, Mitchell D. Wong, MD, PhD, of the UCLA Division of IMMEDIATE PAST PRESIDENT Robert M. Centor, MD • Birmingham, AL General Internal Medicine and Health Services Research discusses his article, [email protected] • (205) 975-4889 “The Association Between Life Chaos, Health Care Use and Health Status TREASURER Among HIV-infected Persons.” Redonda Miller, MD, MBA • Baltimore, MD [email protected] • (410) 955-3010 ew approaches to SECRETARY health care delivery Valerie Stone, MD, MPH • Boston, MA often require astute “They found that higher chaos [email protected] • (617) 726-7708 N observations that develop TREASURER ELECT scores were associated with Jeffrey Jackson, MD, MPH • Bethesda, MD into research foci. These [email protected] • (202) 782-5603 foci can inform and direct those in the sample who were COUNCIL health care delivery. From observation to inquiry to without a significant other, Jasjit Ahluwalia, MD, MPH • Minneapolis, MN [email protected] • (612) 626-6033 practice change, clinical had one or more unmet social Marshall Chin, MD, MPH • Chicago, IL investigators are important [email protected] • (773) 702-4769 conduits for advancing service needs, or had lower Donna L. Washington, MD, MPH • Los Angeles, CA generalist care. The obser- [email protected] • (310) 478-3711 ext. 49479 vation of the problem is mental health status.” Karen DeSalvo • New Orleans, LA [email protected] • (504) 988-5473 often the most important Said A. Ibrahim, MD, MPH • Pittsburgh, PA step. the similarity with some of my own [email protected] • (412) 688-6477 This month in JGIM, Mitchell D. patients in my continuity clinic in East Alicia Fernandez, MD • San Francisco, CA [email protected] • (415) 206-5394 Wong, MD, PhD, describes the genesis Harlem. We only started thinking about of his line of inquiry into “chaos.” He chaos as a research topic after we left EX OFFICIO notes, “The original idea of the research New York the following year.” Regional Coordinator was that of Catherine Sarkisian, my wife Their research involves an investiga- Donald Brady, MD • Atlanta, GA [email protected] • (404) 616-3117 and co-investigator, when we were living tion regarding the development and test- Editors, Journal of General Internal Medicine in New York City over 10 years ago. I ing of a global measure of life chaos for Martha S. Gerrity, MD, PhD • Portland, OR was finishing my primary care Internal adults regarding social and environmen- [email protected] • (503) 220-8262 Ext. 55592 Medicine residency at Cornell/New York tal aspects of life. They further sought to William M. Tierney, MD • Indianapolis, IN Hospital, and she had just finished her examine whether this chaos measure dif- [email protected] • (317) 630-6911 residency and was practicing at Jacobi fers among HIV-infected persons by Editors, SGIM Forum Rich Kravitz, MD, MSPH • Sacramento, CA Hospital in the Bronx. She had this rev- socioeconomic status, social supports, and [email protected] • (916) 734-2818 elation after she saw a particular patient, stressors. They also examined whether Malathi Srinivasan, MD • Sacramento, CA a single mother living in poverty whose life chaos was associated with lower use [email protected] • (916) 734-7005 brother had just been released from jail, of HIV care and worse health status. Associates’ Representative had nowhere to go, and so was coming To achieve their objectives, they Neda Ratanawongsa, MD • Baltimore, MD [email protected] • (410) 550-1862 to New York to stay with her. Of course, examined survey data including measures HEALTH POLICY CONSULTANT the patient had few resources and really of life chaos, health status, and health Lyle Dennis • Washington, DC no room for her brother, but he was care use collected from a sample of HIV- [email protected] coming to stay with her and her children infected persons. They found that higher EXECUTIVE DIRECTOR anyway.” chaos scores were associated with those in David Karlson, PhD He continues, “It suddenly seemed so the sample who were without a significant 2501 M Street, NW, Suite 575 • Washington, DC 20037 [email protected] clear to Catherine why this woman was other, had one or more unmet social serv- (800) 822-3060; (202) 887-5150, 887-5405 FAX having such difficulty trying to check her ice needs, or had lower mental health sta- DIRECTOR OF COMMUNICATION AND PUBLICATIONS finger stick blood glucose levels and tak- tus. They concluded that their measure of Francine Jetton • Washington, DC ing her medications—given what she was chaos was associated with mental health [email protected] • (202) 887-5150 dealing with in her life. She told me status and health care service utilization. about this patient, and I immediately saw continued on page 13 2 SGIM_September 2007-Web.qxd 8/10/07 4:18 PM Page 3 SGIM Forum PRESIDENT’S COLUMN EDITORS IN CHIEF EMAIL “The Vision Thing”: Rich Kravitz, MD, MSPH [email protected] Malathi Srinivasan, MD [email protected] Leadership and MANAGING EDITOR EMAIL Christina Slee, MPH [email protected] SGIM FORUM COLUMN ASSOCIATE EDITOR EMAIL Eugene Rich, MD Abstractions Jeff Jackson, MD, MPH [email protected] ACGIM Anna Maio, MD [email protected] Ask the Expert n this issue, Francine Nina Bickell, MD, MPH [email protected] Jetton has done an Carol Horowitz, MD, MPH [email protected] outstanding job sum- “Of course organizations need Ethan Halm, MD, MPH [email protected] I marizing the outcome of Disparities in Health a vision; that’s Strategic Said Ibrahim, MD, MPH [email protected] the SGIM Council’s June From the Regions planning retreat. This Planning 101. But a shared Keith vom Eigen, MD, PhD, MPH [email protected] leaves me free to reflect vision is a bigger challenge. From the Society more broadly on the lead- Francine Jetton [email protected] ership process and SGIM.
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