Doctors Fear Their ‘Gatekeeper’ Role Results in Inadequate Care
Patients aren’t the only ones worried about access to medical specialists. Turns out, some of their doctors are concerned too.
One in four of the physicians who provide general medical care say they are being asked to treat complicated conditions that would be better left to specialists.
A survey of 12,107 doctors published Thursday in the New England Journal of Medicine found that 24% of primary-care physicians--general practitioners, internists and pediatricians--think that they are being asked by health insurers and other managed care groups to provide a scope of care that is beyond their training.
Many HMOs and other managed care companies generally encourage primary care doctors to oversee treatment of patients and to help control costs by referring patients to specialists only when necessary. They have thus become “gatekeepers” to medical care, lowering overall costs by limiting unnecessary visits to more expensive specialists. Such a role, experts say, has clearly been beneficial.
But critics of managed care say that doctors sometimes are discouraged from referring patients to specialists or are financially rewarded--or penalized--based on the frequency of their specialist referrals.
The public’s perception is often that primary-care physicians “ration care on behalf of profit-maximizing managed care plans or for their own financial interest,” said Dr. Kevin Grumbach of UC San Francisco in an accompanying editorial. That perception further limits their ability to function as effective gatekeepers.
The telephone survey also found that 38% of specialists believe that patients’ health is compromised by delays in referring patients to specialists.
The survey was conducted from 1996-97 by the Center for Studying Health System Change in Washington.
Dr. Thomas R. Reardon, president of the American Medical Assn., said the findings show the need for a national Patients Bill of Rights that would allow easier access to specialist care.
Alternative to Steroids for Asthma Sufferers?
An experimental, genetically engineered drug may offer a new option for asthma sufferers concerned about potentially dangerous side effects from powerful steroid medications.
Dr. Henry Milgrom and his colleagues at the National Jewish Medical and Research Center in Denver found that one in three patients taking the most powerful oral steroids were able to quit taking them after taking an experimental drug called rhuMAb-E25. Forty-three percent of patients taking a lower dose of steroids were able to stop using them.
This study’s findings were reported Thursday in the New England Journal of Medicine.
The experimental drug is an artificial antibody that is directed against an immune globulin called IgE. IgE plays a key role in producing swelling and inflammation of the airway in asthma, which affects one in every 20 Americans.
Milgrom and his colleagues gave a high dose of the antibody to 106 subjects and a lower dose to another 106. A third group of 105 patients received a placebo and counseling about controlling their symptoms.
Officials Warn Against Dietary Supplement Use
State health officials last week renewed their warning about the hazards of 1,4-butanediol following the hospitalization of three Riverside County bodybuilders with acute respiratory failure and delirium within an hour after they consumed a dietary supplement called NRG3. 1,4-butanediol, also known as 1,4-tetramethyleneglycol or Sucol-B, is illegal and has been associated with severe and life-threatening health problems. At least 49 deaths, including two in California, have been linked to its use, and there were 232 hospitalizations associated with it in California last year.
Nonetheless, the supplement continues to be included in a variety of products, including enLiven, Zen, Serenity, Somato-Pro, Orange FX Rush, Lemon FX Drop, Cherry FX Bomb, Borametz, Pine Needle Extract, Promusol and BVM, according to the California Department of Health Services.
Findings Could Lead to Artificial Livers
Researchers have made two new findings that could eventually make it easier to repair liver damage or to produce artificial livers. One study has found the switch that turns liver-cell replication on and off. The second identified a new source of liver cells.
The liver is unique among internal organs in its ability to regenerate itself. When part of the liver is removed, the body produces new cells to return the organ to its initial size. It cannot regenerate if more than two-thirds of the organ is removed, however, and viruses, alcohol and other toxins can destroy so many cells that patients die from liver failure.
Researchers from the Veterans Affairs San Diego Healthcare System, UC San Diego and the Salk Institute for Biological Studies have discovered the molecular switch that tells liver cells to begin dividing. They report in the December issue of Molecular Cell, released Wednesday, that when a phosphate group is attached to a particular protein in liver cells, the cells start replicating. When the phosphate is removed, they stop.
The researchers speculate that drugs could be developed to trigger replication, allowing renewal of damaged liver tissue. The protein switch also could be used to stimulate the growth of liver cells in the laboratory, a feat that is very difficult now. Such cells might then be used in artificial livers.
In a second study, reported in the January issue of Hepatology, researchers from the New York University School of Medicine and Yale University found that bone marrow cells can be converted into liver cells. Researchers have long known that special cells in bone marrow, called stem cells, are the precursors of all the different types of cells found in blood. The new results are the first indication that these stem cells can also be converted into other types of cells.
Using radiation, the team completely destroyed the bone marrow of female mice, then replaced it with marrow from males. Six months later, they found that 2.2% of the animals’ liver cells were derived from the donor stem cells. The team knew the liver cells came from the donated marrow because they contain a Y chromosome, found only in male cells. If researchers can figure out how to convince the stem cells to turn into liver cells, the blood might represent a potential source of replacement liver tissue.
Surgical Applications for ‘Super Aspirin’
A new drug commonly called a “super aspirin,” used in combination with metal stents that prop arteries open, can sharply reduce complications and death rates following balloon angioplasty in diabetics with heart disease, according to a study released Monday. The drug, called abciximab, is an artificial antibody that keeps platelets from clumping and forming blood clots.
A team led by Dr. Steven P. Marso of the MidAmerica Heart Institute in Kansas City, Mo., enrolled 491 diabetics with clogged arteries. One-third underwent angioplasty and received the stent and the drug, one-third underwent angioplasty and received the drug but no stent, while the remainder underwent angioplasty and received a stent, but were given a placebo.
The team reported in Circulation: Journal of the American Heart Assn. that only 8.1% of those receiving the stent and abciximab suffered a reclosing of the artery in the six months following the initial surgery, contrasted with twice that many in the other two groups. The incidence of heart attacks and deaths in the stent-abciximab group was 6.2% in the six months following the procedure, compared to 7.8% in the angioplasty-abciximab group and 12.7% in the stent-placebo group.
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Medical writer Thomas H. Maugh II can be reached at thomas.maugh@latimes.com.
