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15 January 2013 Annals of Internal Medicine Tip Sheet

Below is information about an article being published in the January 15 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Megan Hanks at or 215-351-2656 or Angela Collom at or 215-351-2653.

1. Selective D-Dimer Testing for Suspected Deep Vein Thrombosis Safe and More Efficient than Testing Everyone

D-dimer testing based on clinical pretest probability for deep vein thrombosis (DVT) is safe and reduces diagnostic testing compared with testing all patients. Researchers randomly assigned 1,723 outpatients presenting for the first time with symptoms of DVT to either selective testing (D-dimer testing for patients with low or moderate clinical pretest probability of DVT or venous ultrasonograpy without D-dimer testing in patients with high clinical pretest probability) or uniform testing (testing for all patients presenting with symptoms). Since D-dimer testing is sensitive but not specific for diagnosing DVT, the authors hypothesized that selective testing may be a more efficient strategy than testing all patients. They found that selective testing reduced a proportion of patients who required ultrasonography, and resulted in 21.8 percent fewer patients requiring D-dimer testing. The incidence of venous thromboembolism at three months was 0.5 percent in both study groups, which is considered an acceptable threshold. The authors suggest further studies to determine if a selective strategy can be applied to patients who present with suspected recurrent DVT or pulmonary embolism.

2. Generic ART Effective, Could Save the Health Care System Up to $1 Billion Annually

Treating HIV patients with a combination of generic and branded antiretroviral medications may be an effective and cost-effective strategy. Current HIV treatment guidelines recommend an effective but costly daily dose of one branded combination pill that contains the drugs tenofovir, emtricitabine, and efavirenz. A generic version of lamivudine is currently available, and a generic efavirenz is expected soon. Researchers sought to determine if a once-daily three-pill regimen of generic efavirenz, generic lamivudine, and branded tenofovir could replace the branded one-pill regimen at a reduced cost. Researchers utilized a mathematical model to assess the clinical effect, costs, and cost-effectiveness of a three-pill generic-based regimen compared with the current first-line one-pill regimen. They also projected the potential national savings in the first year after the switch. The researchers found that the three pill regimen was slightly less effective, but could save up to $1 billion annually. According to the author of an accompanying editorial, “The era of generic antiretrovirals in the United States has come.” The author notes that under the Affordable Care Act, drug formulary decisions will be left up to the states. With budgets being squeezed – especially in states opting out of Medicaid expansion – generics will likely get a critical look. The author writes that HIV advocates and caregivers may be more likely to accept generic antiretrovirals if they could see the cost savings being used to address other vital needs within the field of HIV medicine.

3. Survey: State Medical Boards Weigh In on Appropriate Use of Social Media

A national survey of state medical board leadership shows high consensus about which online behaviors would prompt investigation into the physician’s behavior. Researchers partnered with the Federation of State Medical Boards (FSMB) to survey the executive director of each of the 70 state medical and osteopathic boards responsible for licensure and discipline of physicians in the United States. Respondents were presented with 10 hypothetical vignettes of physician online behavior and asked to assess the likelihood of further investigation into a behavior using a four-point scale from “very unlikely” to “very likely.” There was a high consensus among respondents that physicians should never post misleading information about clinical outcomes, use patient images without consent, misrepresent credentials, or inappropriately contact patients. Online behaviors that had a moderate consensus for investigation, or those that were considered a “gray area,” included depicting alcohol intoxication, violating patient confidentiality, or using discriminatory speech. Online behaviors that were not likely to result in investigation included derogatory speech toward patients, showing alcohol use without intoxication, and providing general clinical narratives that did not violate patient privacy. The authors note that many of the online violations would be considered violations offline, too, according to established professional codes. The researchers suggest that standards for online behavior may need to be established as they have been for offline behavior.