Antibiotic giveaways by a growing number of supermarket pharmacies have raised fears among some physicians that they could feel more pressure to prescribe the medications when they are not necessary.
Overuse of antibiotics is blamed for the growth of resistant organisms such as methicillin-resistant Staphylococcus aureus.
Several large grocery store chains with pharmacies have been marketing free 14-day prescriptions of generic versions of the most prescribed antibiotics as a way of helping parents in a flagging economy. Promotions typically run January through March, during the peak of cold and flu season.
The idea is not new. Walker, Mich.-based Meijer began offering free antibiotics -- including amoxicillin and penicillin -- in 2006. But the concept has picked up steam as the economy grows weaker, with more grocery chains jumping on board this winter. Among then are Lakeland, Fla.-based Publix; Giant Food, based in Landover, Md.; Rochester, N.Y.-based Wegmans; and Stop & Shop, based in Quincy, Mass.
Store executives are clear that it's an enticement to draw more customers. But they also say it's a service to families who might otherwise not fill a prescription or see a doctor because of cost concerns.
Parents are already pressuring physicians to give their children antibiotics, even though viruses cause the most common childhood infections, said Wayne Snodgrass, MD, PhD, chair of the committee on drugs for the American Academy of Pediatrics and professor of pediatrics and pharmacology at University of Texas Medical Branch at Galveston. Offers of free medication will probably even more pressure.
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As prescription drug abuse becomes a greater concern among governors and legislators, several states are turning to physicians to help curb the problem through prescription drug monitoring programs. Iowa is the latest state to adopt such efforts.
While the programs have the potential to place physicians in the unwitting position of law enforcement officials, several physician organizations, including the American Medical Association, have expressed support for them. They feel the programs could be a tool for physicians to identify patients in need of help.
According to Sherry Green, executive director of the National Alliance for Model State Drug Laws, there are 38 states with laws authorizing monitoring programs and 32 that have a program up and running. The number of states with monitoring programs has more than doubled since 2002 when the U.S. Dept. of Justice made grants available to create programs.
Under the programs, states create Web sites on which pharmacists report controlled substance prescriptions that are filled. Physicians can gain access to the site to identify possible doctor shoppers or addicts, or even those who might be involved in illegal drug diversion.
Jeanine Freeman, senior vice president of legal affairs for the Iowa Medical Society, said when Iowa received a grant to create a drug monitoring program two years ago the medical society's initial concern was that the program would be established under grant only with no statutory requirement.
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Just weeks before a strict medical privacy law went into effect in California, another major privacy breach was uncovered at a large medical center there -- one that police say led to theft.
A former billing clerk at Cedars-Sinai Medical Center in Los Angeles was arrested in November 2008 and charged with stealing patient records and using the identities to steal from insurers.
James Allen Wilson, whose job authorized him to access to the hospital's electronic medical record system, allegedly set up a fake lab company then used stolen information from patient files to bill insurers. Investigators say the scheme netted Wilson at least $69,000, an amount expected to grow as the investigation continues.
Jane Robison, spokeswoman for the Los Angeles County District Attorney's office, said an insurer brought the alleged violations to the attention of investigators, who then alerted the hospital.
Investigators visited Wilson's home and found the records of more than 1,000 patients and actual workers' compensation claims, police said. The hospital sent letters to all patients involved alerting them to the scheme and advising them that it did not appear the stolen information was being used for anything besides the insurance fraud.
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Even though it believed UnitedHealth Group concealed more than $1 billion worth of stock-option backdating, the Securities and Exchange Commission is letting the company settle its charges without paying a penny in fines. However, another United executive joins the ranks of those who are reimbursing the SEC over their allegedly ill-gotten gains.
The investigation looked into charges the company awarded stock options with a strike price that was tied to the date of its lowest 52-week share price -- rather than to the price on a specified single date -- and did not tell investors of this arrangement.
The SEC said that practice allowed United executives to have stock options worth far more than they would have been otherwise.
The SEC cited United's "extraordinary cooperation in the commission's investigation, as well as its extensive remedial measures" as reasons the company was not charged with fraud, and why it could settle for nothing on charges it violated the reporting, books and records, and internal controls provisions of the federal securities laws. United did not admit or deny guilt.
United, the SEC said, had recouped nearly $1.8 billion in cash and stock-option value through litigation, annulment of options and other means. The company also shared details of its own backdating investigation with the SEC, the agency said.
United instituted controls to ensure backdating would not occur again, the SEC said. Also, United removed senior executives and board members who were deemed complicit, the agency said.
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A desire to continue providing colonoscopy, combined with a lack of resources, led one physician to offer the procedure without sedation. Now, that solution may lead to no-sedation colonoscopy becoming a more widely considered option.
A few years ago, the Sepulveda Ambulatory Care Center in North Hills, Calif., experienced a nursing shortage, and Felix Leung, MD, a staff gastroenterologist, was faced with two options. He could stop performing the procedure, or he could start offering it without sedatives. The Sepulveda center is part of the Veterans Affairs Greater Los Angeles Healthcare System. In response to patients who didn't want to travel 15 miles to another facility, he offered the no-sedation approach. Quite a few -- 30% between 2002 and 2005 -- accepted.
"The veterans asked if there was an alternative, and we found out that unsedated colonoscopy is done in many parts of the world," said Dr. Leung, who also is a professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. "The U.S. seems to be unusual in that we, by and large, only do sedated colonoscopy."
He has since documented his experiences in a series of papers, including one in the December 2008 Journal of Family Practice. This article reported that, from September 2002 to June 2005, 145 out of 483 eligible patients opted to undergo colonoscopy without sedation. Of this group, 112 were able to complete it. Twenty-six could not, because of the discomfort, and later underwent sedated colonoscopy or barium enema. Another seven had poor bowel preparation or obstructing lesions that blocked the procedure. Some physicians said these numbers indicated that unsedated colonoscopy is a viable alternative.
"It's not going to be for everyone, but it's an option that I think patients would want to consider," said Thomas Kintanar, MD, a family physician in Fort Wayne, Ind. "There are some patients who will do just great without any anesthetic." He is also a board member of the American Assn. for Primary Care Endoscopy, although he was speaking for himself.
Colonoscopies without sedation are common in Europe and Asia.
Colonoscopy without sedation is common in Europe and Asia, and efficacy is comparable.
"There have been several studies that show that if you have motivated patients, a significant fraction of them can have a colonoscopy without sedation," said Douglas Rex, MD, past president of the American College of Gastroenterology. "But what has to be kept in mind is that most American patients actually prefer to be sedated. If you use sedation, there is better patient satisfaction and better physician satisfaction. That's really important."
Dr. Rex, who is also professor of medicine at Indiana University School of Medicine and director of endoscopy at Indiana University Hospital, has performed a small number of colonoscopies on unsedated patients and has undergone one without sedation himself. "For the great majority, having sedation offers a lot of advantages and a lot of positives," he said.
But with the demand for colonoscopy growing, performing it without sedation could reduce both associated work force needs and costs to the health care system. In his efforts, for instance, Dr. Leung eliminated the need for two registered nurses.
Also, a report released Jan. 7 by the Lewin Group, a health care consulting firm, projected that demand for gastroenterologists would grow at a rate nearly double the supply. If this projection bears out, it could impact the availability of traditional colorectal cancer screening, thereby increasing interest in the no-sedation option.
Neither the American Gastrological Assn. nor the ACG has policy regarding no-sedation colonoscopy. In broader terms, ACG policy notes that a well-trained endoscopist is key to a good colonoscopy. The American Academy of Family Physicians takes the position that family physicians trained in colonoscopy should be allowed to perform them and that specialty should not affect privileging.
Going without sedation also could provide some benefits for patients. Dr. Leung discovered many preferred being able to communicate and remember the conversations with the physician during and after. In addition, the unsedated approach is less expensive and does not require patients to have an escort or restrict activities afterward.
"Some patients just didn't have anybody to shuttle them around, and these patients would not have been able to have screening by colonoscopy if this option was not available," Dr. Leung said.
Additionally, this approach cuts to zero the already very low risk of complications associated with the sedative medications and significantly reduces the chance of a perforation.
"You cannot perforate [the bowel of] an awake patient. They will get off the table and smack you," said Ricardo G. Hahn, MD, professor of family medicine at the University of Southern California in Los Angeles. Unsedated colonoscopy is "not a comfortable procedure, but it's only once every five to 10 years."
Dr. Hahn co-authored a paper in the September-October 2007 Journal of the American Board of Family Medicine comparing unsedated colonoscopy with flexible sigmoidoscopy in a family medicine clinic.
Several physicians, however, expressed caution, because unsedated colonoscopy may not be possible or appropriate for everyone. Data from a VA population, which tends to be older and predominantly male, may not apply to the wider world. For example, female physiology tends to make this procedure more difficult.
Experts also worry that an uncomfortable experience may keep a patient from completing this screening.
"The key for us is to ensure a good exam, a comfortable exam for the patient and one that they are willing to repeat," said David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine. He also is an ACG past president.
Dr. Leung's upcoming projects will look at colonoscopy techniques, such as using water infusion without air insufflation, to reduce the discomfort related to the procedure and allow more patients to have it done without or with less sedation.
The print version of this content appeared in the Jan. 19, 2009 issue of American Medical News.