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Ranked by total HMO enrollment as of 7-1-2002

Students who aspire to become medical directors because they think it's a laid-back desk job are in for a rude awakening. Unlike the clinical executives of the past, today's medical directors and chief medical officers (CMOs) have enterprising issues on their desks, sprawling out to the remotest edges in the continuum of care.

All of the computer information technology in the world does no good if you don't have the discipline to act on what it's telling you to do. Not only does Kent Clapp, chairman, president and CEO of Medical Mutual of Ohio, apply this principle to running his own organization, he believes it's equally relevant to healthcare consumers.

Returning to the workplace after a diagnosis and treatment of cancer raises many issues for employee and employer alike. Two experts in the field explain why the challenges may not be as daunting as they first seem.

Estrogen plus progestin therapy does not prevent mild cognitive impairment (MCI) in women aged 65 years and older, and it increases the risk for probable dementia in this group, according to researchers from the Women's Health Initiative Memory Study (WHIMS).

Individuals with diabetes are more prone to cardiovascular morbidity and mortality. However, because their low-density lipoprotein (LDL) cholesterol is similar to that of the general population, they do not usually receive statin or other cholesterol-lowering therapy.

Cyclooxygenase-2 selective inhibitiors, better known as coxibs, may not be cost-effective for treatment of chronic arthritis pain in patients at average risk for ulcer complications as compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), according to a study recently published in the Annals of Internal Medicine. Using a coxib versus a NSAID cost an incremental $275,809 per year to gain 1 additional quality-adjusted life-year (QALY). For patients with a history of bleeding ulcers, however, the incremental cost per QALY gained decreased to $55,803.

Fondaparinux (Arixtra, Organon/Sanofi-Synthelabo) is at least as effective and safe as the low molecular weight heparin (LMWH) dalteparin for the prevention of venous thromboembolism (VTE) following major abdominal surgery, according to results from the Pentasaccharide in General Surgery Study (PEGASUS). Fondaparinux is the first and only synthetic selective Factor Xa inhibitor indicated for the prophylaxis of deep vein thrombosis (DVT).

Current medical therapy for chronic stable angina (CSA) is targeted at reducing the frequency of anginal symptoms and improving exercise tolerance by increasing myocardial oxygen supply and/or reducing myocardial oxygen demand. Pharmacological therapy for CSA is limited since traditional agents provide pain relief by reducing the work of the heart or dilating arterioles in an attempt to enhance supply. Combinations of these agents can induce profound reductions in blood pressure that limit the aggressive dosing needed in some patients. Metabolic modulators seek to overcome this issue through a novel mechanism of action. Ranolazine (Renexa, CV Therapeutics) is a partial fatty oxidase (pFOX) inhibitor that increases the amount of ATP produced from glucose and increases the ability of the myocardium to retain functionality despite a reduced oxygen supply. (Formulary 2003;38:461?476)

Patients with diabetes are at extremely high risk for cardiovascular disease. Because glucose control is associated with only modest reductions in macrovascular complications, efforts must be made to specifically target other cardiovascular risk factors. Diabetes is associated with a characteristic lipid profile: low high-density lipoprotein cholesterol (HDL-C) and high triglyceride levels with or without high low-density lipoprotein cholesterol (LDL-C) levels. This profile is also found in patients with early-onset coronary heart disease and correlates with increased atherogenesis. Multiple clinical trials have demonstrated that lipid-modifying therapy in patients with diabetes decreases cardiovascular risk. Management targeting all lipid abnormalities may represent the best treatment strategy since many patients with diabetes do not have elevated LDL-C levels. Combining lipid-modifying agents is also an attractive option for normalizing multiple lipid abnormalities. (Formulary 2003;38:478-497)

Managed care is especially vulnerable to cybersabotage because of consolidations and corporate growth.

What is predictive modeling and how can you leverage it

Protect your company from a crime that's on the rise

Impediments are present for new technology adoption, among them are cost and turf

IHN longevity

Kaiser Family Foundation Health Poll Report

Collective bargaining for better prices is among the many valuable benefits of creative partnering

Points to consider with plan beneficiaries and physician compensation arrangements

by degree of integration and performace level, 2003

When Destiny Health Plan launched its consumer-driven healthcare solution in the United States in 2000, it wasn't a shot in the dark. Its parent company, Discovery Health, headquartered in Johannesburg, had already proven the consumer-driven model's success in South Africa 10 years before. With a little tweaking to fit the U.S. marketplace, the healthcare product has taken off, serving 23,000 members and 700 employer groups.

We all remember how difficult things got for the managed care industry in the mid-to-late 1990s, but as they say: When the going gets tough, the tough get going.

Alzheimer's disease currently has no cure and is estimated to cost in excess of $100 billion per year.

Long-term treatment of 384 adults ADHD patients with atomoxetine (Strattera, Lilly) showed that 67% responded with at least a 30% improvement and 40% had at least a 50% improvement.

Metformin use in hospitalized patients is inappropriate more than one-third of the time.

Premeal dosing of inhaled insulin may represent a valuable option for patients with type 2 diabetes.

Approved for pediatric chronic myeloid leukemia

Treatment and prevention of osteoporosis

Panic disorder is the most common anxiety disorder in the primary-care setting. It is characterized by episodes of acute, unexpected, and unprovoked anxiety and is often associated with depression and/or agoraphobia. Symptoms may become so pervasive that many life situations may be avoided. Management of panic disorder includes cognitive behavioral therapy, patient education, and pharmacotherapy. This article focuses on the rationale of drug therapy, methods of management, and other clinical considerations such as side effects. In addition, newer formulations are available that may subsequently change how patients are managed. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line therapy, with tricyclic antidepressants (TCAs) as a possible alternative if the patient fails to respond. These agents are also useful in the management of comorbid depression. Benzodiazepines offer more rapid anxiolysis and may be used in combination with an SSRI for bridging. Although monoamine oxidase inhibitors (MAOIs) have been studied, they do not have a significant role in the pharmacological management of panic disorder. (Formulary 2003;38:431?38.)

Nausea and vomiting are among the serious complications of chemotherapy and can be associated with medical and psychological complications. Palonosetron (Aloxi, MGI Pharma/Helsinn) is a new agent in the class of serotonin type 3 (5-HT3) receptor antagonists that have become a standard of care for the prevention of chemotherapy-induced nausea and vomiting. Palonosetron has a much longer half-life (~40 h) than typical 5-HT3 receptor antagonists and potentially improved efficacy in the prevention of delayed nausea and vomiting associated with moderately and highly emetogenic chemotherapy. Clinical trials of palonosetron in patients with cancer demonstrate its efficacy in the control of acute nausea and vomiting and its superiority to 2 agents in this class, dolasetron and ondansetron, in the control of delayed nausea and vomiting. Palonosetron is well-tolerated, with an adverse effect profile similar to other 5-HT3 antagonists. Its efficacy in the prevention of both acute and delayed nausea and vomiting makes palonosetron an attractive option for patients receiving chemotherapy. Further studies need to be conducted to determine the role of palonosetron among its competitors. (Formulary 2003;38:414?430.)

Formulary committees, pharmacy benefit managers (PBMs), pharmacists, and physicians face increased scrutiny of their relationships with pharmaceutical manufacturers under a final fraud policy statement from the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS).