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Researchers Devise Chest Pain Rule

The Vancouver Chest Pain Rule can identify chest pain patients who can be safely and speedily discharged from the emergency department after a two-hour evaluation, according to a study published as an early online release Oct. 19 by the Annals of Emergency Medicine.

The rule identified 35.2 percent of patients who did not have acute coronary syndrome during a two-hour evaluation in the emergency department, wrote the authors, led by Jim Christenson, MD, of the University of British Columbia and St. Paul's Hospital. It was 98.8 percent sensitive, identifying all but two patients with unstable angina.

The study collected data from 769 patients at least 25 years old who presented to St. Paul's Hospital, an urban tertiary care emergency department, with a primary complaint of anterior or lateral chest pain, in two separate periods between June 29, 2000, and Jan. 24, 2003. Investigators used predefined explicit criteria to assign a 30-day outcome diagnosis of acute myocardial infarction, definite unstable angina, or no acute coronary syndrome. Of the 769 patients, 77 (10%) had acute myocardial infarction and 88 (11.4%) had definite unstable angina.

Age, initial history, and electrocardiogram results identified 56 of 198 patients who ultimately met the rule criteria. Then 121 patients were identified based on initial creatine kinase MB and low-risk pain characteristics. The last 21 patients were identified by the absence of changes in the electrocardiogram or serum markers during two hours. This study did not prospectively evaluate the rule.

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FDA Brings Its Agenda to the Public

To counteract some of the recent damaging publicity about its ability to ensure pharmaceutical safety, the Food and Drug Administration held a series of public meetings called “Vision 2006: A Conversation with the American Public.” The meetings discuss[ed] five agency programs or initiatives: drug safety, direct-to-consumer advertising, dietary supplements, the Critical Path initiative, and the advisory committee process and how potential conflicts of interest are managed. The Critical Path initiative is a 2004 report that identified potential problems and solutions to ensure that breakthroughs in medical science can be efficiently translated to safe, effective, and available medical products, underscoring the importance of FDA collaboration with academic researchers, product developers, patient groups, and other stakeholders to make the critical path more predictable and less costly.

The FDA held the meetings to engage the public in discussion and obtain consumer input on specific issues, hoping to strengthen the FDA's understanding of the public's expectations and concerns and help the agency evaluate and modify its programs and activities.

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Florida Physicians Cut Health Services

Physicians across Florida continued to decrease or eliminate health services in 2004, and the challenge of finding or paying for professional liability insurance seemed to be the culprit, according to a survey reported in the Oct. 10 issue of Archives of Internal Medicine.

The researchers, led by Robert G. Brooks, MD, of the division of health affairs and the department of family medicine and rural health at the Florida State University College of Medicine in Tallahassee, initially studied the potential relationship between liability insurance and physician services in 2003 and revisited the question using 2004 data after Florida passed legislation to reform and stabilize the professional liability insurance market.

In the more recent study, which included physicians practicing in rural and urban/suburban areas of Florida, 1,346 (39.4%) of the 3,413 surveys were returned. Overall, 727 (54.4%) of respondents reported that they had decreased or eliminated patient services during the previous year, a number which included 380 (56%) rural and 347 (52.4%) urban/suburban physicians. The most common services eliminated were nursing home coverage (42.1%), vaginal deliveries (29.1%), Cesarean deliveries (26.0%), emergency department coverage (22.8%), and mental health services (21.2%). In addition to outright elimination, many physicians reported that they had decreased services in these areas.

Surgical specialists (70.2%) and general surgeons (68.5%), respectively, had the highest number of decreased or eliminated services. Obstetrician-gynecologists (63.6%) and family medicine physicians (60.2%) also were represented in this group. Pediatricians were the only group in which less than half (41.5%) of the respondents indicated that they had not decreased or eliminated services in the last year. No significant differences were noted between rural and urban/suburban physicians in decreasing/eliminating services.

New limits in services appeared to be related to changes in liability insurance premiums. Physicians who had premium changes in the highest quartile, which signified an increase of more than 50 percent, were more likely to decrease or eliminate services than those in the lowest quartile, which was defined as a premium increase of less than 15 percent. Of 713 physicians who decreased or eliminated services, 58.3 percent said paying for liability insurance played a “large role” and 30.3 percent said it had played “some role” in decreasing or eliminating these services.

© 2006 Lippincott Williams & Wilkins, Inc.

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