family physician news(ckd) has become epidemic.1greater awareness of ckd and improving survival from...

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Providing scientific information,practice management strategies andACOFP news for the communityof osteopathic family physicians

President’s Perspective

Change andCommitment PA G E 3

Washington Update

New Bills Look Promisingfor Family Physicians PA G E 4

Special Articles

OFP’s Approachto Osteoporosis PA G E 1 4

ePrescribing Tops2008 HealthInformation List PA G E 1 6

Membership Matters

New ACOFPMembers PA G E 1 8

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Reducing Cardiovascular Risk and ESRD In Chronic Kidney Disease PatientsBy Samuel Snyder, DO and Danielle Thomas, DO

CMEArticle

Heart Disease PreventionBy Eric Felber, DO

This is the first place winner of the 2008 Namey/Burnett Writing Award. The Namey/Burnett Writing Award is implemented by the ACOFP PreventiveMedicine and Medical Preparedness Committee to honor the best preventivemedicine papers submitted by osteopathic family practice residents, interns, andosteopathic medical students.

Heart disease is the number one cause of death in the United Statesaccording to the Centers for Disease Control.1 In 2004, heart dis-ease accounted for 652,486 deaths out of a total of 2,397,615

deaths.1 Twenty-seven percent of all deaths are caused by heart disease.Interestingly, the number of deaths from heart disease has decreased since2000 when there were 710,760.1 The next most common causes of deathare cancer (553,888),stroke (150,074), chronic lower respiratory diseases(121,987), accidents (112,012), and diabetes (73,138).1

The incidence of heart disease increases with age and is increased withseveral risk factors. The number of cardiac deaths is greater than the third,fourth, fifth, and sixth most common causes of death combined.

continued on page 10 =

ABSTRACT: Over the last decade, chronic kidney disease(CKD) has become epidemic.1 Greater awareness of CKDand improving survival from cardiovascular disease arepartial explanations, as are the increasing prevalence ofdiabetes mellitus, dyslipidemia, obesity, hypertension, andmetabolic syndrome. According to the United States RenalData Service, prevalence of CKD has risen 84 percent since2001. But very few of these will progress to End Stage RenalDisease (ESRD), or dialysis dependent renal failure. Instead,the majority will experience cardiovascular death. Mostimportantly, timely cooperation between primary care physi-cian and nephrologist translates to improved survival. It isthe joint responsibility of the primary care physician and thenephrologist to work together to improve this alarmingmortality statistic.

Over the last decade, chronic kidney disease(CKD) has become epidemic.1 Greater aware-ness of CKD and improving survival from

cardiovascular disease are partial explanations, as are theincreasing prevalence of diabetes mellitus, dyslipidemia,obesity, hypertension, and metabolic syndrome.According to the United States Renal Data Service(USRDS), prevalence of CKD has risen 84 percent since2001. Medicare expenditures have risen dramatically,and in 2003 were estimated at $37 billion.1

The NationalKidney Foundationhas established ascheme for stagingCKD (Table 1)based on newerunderstandings ofthe epidemiologyand relative risk ofdifferent levels ofrenal insufficiency.2

Overall, the preva-lence of CKD isestimated as 11percent of the U.S.population,accounting formore than 20million people.3

But very few of these will progress to End StageRenal Disease (ESRD), or dialysis-dependent renalfailure. As of 2003 USRDS data, there were about453,000 ESRD patients. Fewer than 1 million personsare thought to be in Stages 4 and 5.1 Most individuals inStage 3 will never progress. Instead, the majority willexperience cardiovascular death.

continued on page 6 ==

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It was a great conventionweek in Denver. Theweather was beautiful and

the mountains magnificent.Drs. DeLuca, Galluzzi andSmith put together awonderful program and theeducation was scientifically-based and top notch. Thefellowship and social eventsprovided all with an opportu-nity for revival of friendships

and renewal of commitment to osteopathic philos-ophy and principles. Twenty new Fellows werehonored along with three new DistinguishedFellows, more than 200 residents and physicianstook certification and re-certification examinations,adding to the depth and talent of the profession.More than 350 students and residents experiencedthe atmosphere of being a member of our profession,an air of a family reunion and homecoming inaddition to a great educational experience.Thanks to each of you who attended and my

personal regrets to all of those who did not, youmissed a great event. I want to thank you for the honor of serving as

your President for the coming year. I pledge that Iwill work hard to honor the office and representeach of you and our profession well during the year.

Change for CommitteesThis convention marked a change in operation

for ACOFP. The 2008-2009 new committees metat the convention, prepared to function and expectedto act. They had detailed for them committee goalsand actions plans for the coming year before themeeting and the committee’s leadership wasprepared to act decisively from the first meeting ofthe year. I appreciate the dedication and leadershipprovided by our members and volunteers.

The Board is in the process of developing a newstrategic plan to guide our actions into the nextdecade. I encourage each member’s input andcomments when it is released in the weeks to come.One of the key components of the new strategic

plan will be a critical analysis of all functions andcommitments to ensure that they meet the currentneeds of our members and utilize your resources inthe most effective and efficient manner.

Some of our areas of emphasis and actions thisyear are sketched below. For more information, Iencourage you to review my presentation to theCongress and my Banquet speech, both of which areposted on acofp.org. In addition, each of you iswelcome to contact me personally at any time forinformation or seeking answers to your questions.

Commitment to AdvocacyThis year, we will be expanding our efforts in

advocacy at national and state levels. ACOFP, asthe only affiliate that directly supports the AOAin its efforts to represent osteopathic medicineand its Department of Government Affairs inWashington, DC, has represented osteopathicfamily physicians at the federal level for manyyears. The ACOFP maintains a full-timeDirector of Government Relations in

Washington, DC, Ray Quintero, and he is instru-mental in ensuring osteopathic family physiciansare represented and defended in governmental andregulatory circles. Mr. Quintero, along with Dr.Olivia, guide our efforts and coordinate ouractions with those of the AOA and its Director ofGovernment Affairs, Shawn Martin. We are committed to additional dedication of

resources, time and talent to affect items ofconcern to our members in the year to come. Weare working to modify not only the SGR but allpayment systems, seeking equitable and appro-priate reimbursement for the patient care servicesprovided by primary care physicians. We arecommitted to never stop seeking equitable reformof this country’s tort system. We are lobbying forimprovements in the current system of GME thatbetter reflect the needs and contributions ofosteopathic medicine and osteopathic familymedicine in our health care system. In addition, a new State Legislative Affairs

Committee is charged to assist our members andaffiliates when matters of regulatory and legisla-tive affairs arise that affect practice rights, privileges, and reimbursement.

Change for GMEACOFP is committed to quality pre-doctoral

and graduate medical education. We are workingto critically examine and modify where indicatedall standards that regulate our residencies and thetraining of our students and residents. Inaddition, a new committee is developed to provideadded support for the osteopathic family medicinefaculty at our colleges of osteopathic medicine. We must ensure that our GME programs are

competitive for our graduates and that thoseosteopathic residencies are perceived as the goldstandard for the training of family physicians.This year, while an increased number of U.S.graduates entered family medicine residencies, thepercentage of osteopathic graduates that enteredour profession declined once again, and thenumber and percentage of osteopathic graduatesthat entered allopathic programs hit an all timehigh. Our programs must reflect and educate ourstudents about the demands of practice today andthe requirements for tomorrow. Changes are required to ensure that our

programs provide the knowledge, skills andcompetencies required to meet the needs of theirpatients and practices. Programs must providediverse training models desired by our graduatesand they must aggressively compete for ourgraduates. Standards must ensure that theyprovide expertise in the business of medicine andevolving delivery systems such as the medicalhome and pay for quality systems, educate ourresidents in the procedures required to providequality medical care and to prepare our graduatesto be economically successful during their careers. We must continue to celebrate our uniqueness

and ensure that all osteopathic family physiciansare competent in and place an emphasis onOPP/OMM skills and procedures.

president’sP E R S P E C T I V E

Ronnie B. Martin,DO, FACOFP dist.

Change and Commitment

OFP NEWSOsteopathic Family Physician News provides

scientific information, practice managementstrategies, and ACOFP news for thecommunity of osteopathic family physicians.

Ronnie B. Martin, DO, FACOFP dist.PresidentJoel A. Kase, DO, MPHEditorPeter L. Schmelzer, CAEExecutive DirectorHeather M. BergManaging EditorStacy E. JacobsPublications & Web Site Designer

Editorial Advisory CommitteeKevin V. De Regnier, DO FACOFP, Dept. ChairAlice J. Zal, DO, FACOFP, ChairRobert N. Pedowitz, DO Vice ChairSteven R. Blasi, DOMaria F. Daly, DO FACOFPLinda I. Greenspan, DO FACOFPJoan M. Grzybowski, DO FACOFPMatthew B. Harrison, DOSteven K. Kamajian, DOJoel A. Kase, DO, MPHChristopher J. Mehallo, DOAnthony J. Silvagni, DO FACOFP dist.Joel D. Stein, DO FAAO FAOASMChristopher P. Zipp, DO

ACOFP Headquarters Office330 E. Algonquin Road, Suite 1Arlington Heights, IL 60005(ph) 800-323-0794 (fax) 847-228-9755Web site: [email protected]

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Instructions for AuthorsArticles submitted for publication must be original in nature andmay not be published in any other periodical. Materials forpublication should be of clinical or didactic interest to osteopathicfamily physicians. Any reference to statistics and/or studies mustbe footnoted. Material by another author must be in quotationsand receive appropriate attribution. The ACOFP reserves theright to edit all submissions. Submit typed copy via e-mail [email protected].

All opinions expressed in OFP News are those of the authorsand not necessarily those of the editors, the ACOFP, or theinstitution with which the authors are affiliated, unlessexpressly stated.

ISSN: 1934-3094

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O S T E O PAT H I C FA M I LY P H Y S I C I A N N EW S A P R I L 2 0 0 8 3


washingtonU P D A T E

New Legislation Look Promising for Family Physicians, Medical Home By Marcelino Oliva, DO, FACOFP and Mr. Ray Quintero

Physician Payment Update – “Save Medicare Act of 2008” Introduced

On March 13, Sen. Debbie Stabenow (D-MI)introduced the “Save Medicare Act of 2008”(S. 2785). The bill aims to address the

projected physician payment cuts for the next 18months. Additionally, the bill would extend the Physi-cian Quality Reporting Program (PQRI), incentivepayment programs for physician scarcity areas, and thefloor on Medicare work geographic adjustment(GPCI). Notably, the bill also includes two important“Senses of the Senate” regarding fiscal responsibilityand quality reporting.The specific provisions of the bill include:

• Extension of current law to provide positive 0.5percent updates to physicians for all of 2008; thus,preventing the scheduled 10.6 percent cut on July 1• 1.8 percent update to all physicians for all of 2009;thus, preventing anticipated cuts

• Extension of the PQRI program until January 1, 2010• Extension of the Medicare incentive paymentprogram for physician scarcity areas through January1, 2010

• Extension of the floor on Medicare work geographicadjustment (GPCI) through January 1, 2010

The bill also includes a “Sense of the SenateRegarding Fiscal Responsibility” that requests this billbe deficit neutral over the 5-year period beginningOctober 1, 2008 and requests Congress address thechallenges facing the Medicare program with fiscalresponsibility. The “Sense of the Senate RegardingQuality” requests the Medicare program to providephysicians with positive payment incentives to partici-pate in voluntary quality programs and financing forthese incentives be non-punitive and therefore exemptfrom the Medicare physician fee schedule budgetneutrality requirements.

Budget Resolutions AdoptedOn March 13 and 14, the House and Senate respec-

tively adopted Fiscal Year 2009 budget resolutions.These resolutions are non-binding, but set aggregatespending and revenue targets for the fiscal year. Theresolutions offer Congress a mechanism to outline broadpolicy goals separate from those of the President, whosubmitted his budget request to Congress in February.The House adopted its resolution (H Con Res 312)

212:207 with no Republicans voting for the plan aswell as 16 Democrats voting against it. The Houserejected a substitute amendment offered by the Repub-

lican minority 157:263. Substitute amendments alsowere offered by the Congressional Black Caucus andthe Congressional Progressive Caucus, and were subse-quently not agreed to.The Senate adopted its budget resolution

(S Con Res 70) 51:44 after voting on dozens of amend-ments in a marathon 15-hour session. Two Republicans,Sens. Susan Collins (R-ME) and Olympia J. Snowe (R-ME), voted for the proposal and one Democrat, Sen.Evan Bayh (D-IN), voted “no.” Both the House and Senate budget resolutions would

allot more discretionary spending for the 12 annualappropriations bills than the $991.6 billion proposed bythe President. The House plan calls for a $25.4 billionincrease above President Bush’s request, while theSenate version would provide $21.8 billion more. Bothnumbers include funding for advanced appropriationsprovided in the resolutions but not “emergency”spending, which does not count against budget spendingcaps.The House passed measure includes instructions that

could be used for future Medicare legislation and theSenate measure does not. However, if the House andSenate chambers agree on a final budget blueprinttogether, the House-approved Medicare instructionscould be included. This reconciliation language allowslegislation to move in the Senate with protection againsta filibuster if the measure reduces the federal deficit,needing only a simple majority to pass rather than thecurrently required 60 votes. Discussions in conferencewill begin after Congress returns the week of March 31from their spring recess.

HELP Committee Workforce HearingOn February 12, the Senate Health, Education,

Labor, and Pensions (HELP) Committee held a hearingentitled “Addressing Healthcare Workforce Issues forthe Future.” The hearing was intended to address thecurrent and upcoming physician shortages. Testimonyand discussion at the hearing surrounded the generaltheme that primary care shortages must be addressedimmediately. Rural and underserved areas are sufferingthe most and need help.Solutions considered were establishing new primary

care residency slots, increasing physician reimbursement,dramatically increasing funding for Title VII and NHSC,and creating new and expanded loan forgiveness programsfor students. While there were no conclusions drawnbeyond the idea that something must be done to fix thisproblem, clarity was gained in understanding howincreasing coverage to uninsured Americans would notmean guaranteed access to physicians due to shortagesthat exist.The American Association of Colleges of Osteo-

pathic Medicine and the American OsteopathicAssociation submitted a joint written testimony tothe Senate HELP Committee on behalf of the osteo-pathic profession.


The “Sense of the Senate Regarding Quality” requests the Medicare pro-

gram to provide physicians with positive payment incentives to partici-

pate in voluntary quality programs and financing for these incentives be

non-punitive and therefore exempt from the Medicare physician fee

schedule budget neutrality requirements.

washingtonU P D A T E


MedPAC UpdateAt its March 5-6 meeting, the Medicare

Payment Advisory Commission (MedPAC)examined bundled payments for episodes of treat-ment around a hospitalization as a way toimprove the accountability for cost and quality ofcare. The bundled payment would be shared bythe hospital and physicians involved in theinpatient care. At previous meetings, MedPACdiscussed actual and virtual bundling. Due to the complexities with bundled

payment, MedPAC is considering an incrementalapproach that would involve virtual bundling forall providers. Commissioners also are consideringbundled payments in the context of a pilotprogram. With virtual bundling, the regular fee for

service system would be retained; however,payments would be adjusted to hospitals andinpatient physicians based on aggregate use ofservices over an episode. CMS would take awithholding from all hospital and physicianinpatient services for select conditions. CMSwould refund the withholding to all except thosewith high spending across the episode of care.Those with low spending who also have highquality would have their withholding refundedplus receive a bonus payment. Commissioners were generally supportive that

bundled payments could lead to cost savings andgreater efficiency. They also acknowledged that abundled payment system would require a lot ofwork and drain resources out of the Centers forMedicare & Medicaid Services. Some commis-sioners thought bundling could drive physiciansand hospitals to a new way of interacting andimprove coordination of care. Commissioners alsoconsidered the idea of including outpatient physi-cians involved in post acute care. “We have tofigure out how feasible that is. This could evolveover time,” said Chairman Hackbarth. Draft recommendations:

• Congress should require CMS to confidentiallyreport provider resource use around hospitaliza-tion. After two years, Congress should imple-ment virtual bundling which reduces paymentto hospitals and inpatient physicians withrelatively high resource use across episodes ofcare for select conditions. The payment penaltycan be used to finance additional payments tohigh quality fee for service providers withrelatively low average resource use.

• Congress should require CMS to create avoluntary pilot program to explore issuesrelated to actual bundled payment for servicesaround a hospitalization. (Under actualbundling, hospitals and physicians would get aflat fixed rate whatever the level of services theyprovide.)Commissioners also examined promoting the

use of primary care. MedPAC is considering twoinitiatives: 1) Adjust the fee schedule to promoteprimary care and 2) Medical homes. MedPACcommissioners are examining the use of selectedpractitioners and the statutory definition ofprimary care services for the fee schedule adjust-ment. The adjustment would be budget neutral.

Regarding medicalhomes, physicianswould receive amonthly payment perbeneficiary for themedical home infra-structure and activities.Pay for performanceincentives would alsobe included. There was support

among commissionersfor these initiatives.There were concernsabout budgetneutrality. In addition,there were calls to fixthe RUC and RVUs.Commissioners alsohad questions about what MedPAC was trying toachieve. The purpose is not to deal with thesupply of primary care physicians, but toencourage and recognize these physicians.Hackbarth called it a value proposition to rewarda category of services because of their value to thepatients. This is a bonus for those practitionerswho are deeply involved in these services. Draft recommendations:

• Congress should establish a budget neutralpayment adjustment for primary care servicesbilled under the physician fee schedule. Theadjustment would increase payment for primarycare services if a practitioner designated by theSecretary as primary care furnishes the service.

• To implement the fee schedule adjustment forprimary care, Congress should direct the Secre-tary to identify the physician specialty that canreceive the adjustment. The Secretary shoulduse rulemaking to determine criteria to identifyqualifying primary care physicians. Draft recommendation on medical homes:

• Congress should initiate a medical home pilotproject in Medicare. Eligible medical homesmust meet stringent criteria including at leastthe following capabilities: - Furnish primary care- Use health information technology- Conduct case management- Maintain 24-hour patient communication and access

- Keep up to date records of patients’ advancedirective- Be accredited and/or certified from anexternal accrediting body. MedPAC also considering the following

recommendations for Part D:• The Secretary should develop a measure ofbeneficiary access that calculates whetherbeneficiaries get a prescribed drug or its alter-native without undue delay.

• The Secretary should require plans to transmitinformation to pharmacies when they reject aprescription stating why the drug is not coveredand if the plan covers a clinical alternative. MedPAC also explored options on charging an

independent entity to sponsor and disseminateresearch on comparative effectiveness. Commis-

sioners discussed what the entity would look like,the makeup of an advisory board that wouldoversee activities; and program funding. Therewere no draft recommendations for this issue.

Medicaid FMAP IncreaseOn February 7, Reps. Frank Pallone (D-NJ),

Chairman of the House Energy and CommerceSubcommittee on Health, John Dingell (D-MI),Chairman of the House Energy and CommerceCommittee, Peter King (R-NY), and TomReynolds (R-NY) introduced legislation thatwould provide a temporary increase in theMedicaid federal medical assistance percentage(FMAP) enabling states to continue to providehealth care assistance to its low-income residents.The bipartisan legislation would:• Provide a temporary increase of the MedicaidFMAP by 2.95 percent for five quarters, thelast two quarters of fiscal year 2008 and the fistthree quarters of fiscal year 2009 (April 1, 2008through June 30, 2009.);

• Provide a similar temporary increase of theMedicaid FMAP by 5.9 percent for the territo-ries;

• Protect states against a decline in theirMedicaid FMAP during the same five quartersof the 2008 and 2009 fiscal years;

• Require states to maintain their Medicaid eligi-bility at current levels in order to receive the2.95 percent temporary increase in theMedicaid FMAP; and

• Require states to adjust payments by localitiesand counties to the state share to account foradditional federal funding.In 2003, Congress passed and President Bush

signed into law an economic stimulus packagethat included a similar FMAP increase at a costof $20 billion. �

Marcelino Oliva, DO, FACOFP chairs the ACOFPCommittee on Federal Legislation. Ray Quinteroserves as ACOFP’s Director of Governmental Affairs.ACOFP members may contact Mr. Quintero at 800-962-9008, extension 8648 or by e-mail at [email protected].


caringF O R P A T I E N T S

Reducing Cardiovascular Risk and ESRD In Chronic Kidney Disease Patients

continued from page 1==

In validating the staging of CKD,there has been tremendous reconsidera-tion of assessment of renal function.Serum creatinine alone has proven to betoo inaccurate. Twenty-four hour urinecollections for creatinine clearancebetter represent renal function better,but are fraught with collection error. For many years the Cockcroft-Gault

equation has been used to estimatecreatinine clearance at the bedside. Thismethod is inaccurate at the extremes ofrenal function, the extremes of age, and whencomparing individuals of different race or differentmuscle mass. Glomerular filtration rate (GFR) isconsidered the gold standard of renal function, and canbe assessed with nuclear scans as iothalamate clearance. At the bedside, GFR is now most often estimated

using the Modified Diet in Renal Disease (MDRD)equation, which is creatinine based, but also includesthe influence of age, race, and nutrition (BUN,albumin). However the MDRD equation is still subjectto debate, and the best way to assess renal functionremains uncertain.In the 1990’s, the prevailing paradigm in treatment

of CKD was renoprotection. Emphasis was placed onuse of angiotensin converting enzyme inhibitors, bothto treat hypertension, and to reduce the rate ofprogression of azotemia. As our perspective on CKDhas grown, the paradigm has transformed to one thatfocuses on risk reduction, paralleling the therapeuticmomentum in cardiovascular disease. This is reflectedin the evidence based recommendations of the KidneyDisease Outcome Quality Initiative (KDOQI), aconsensus committee of expert opinion and currentevidence in nephrology.4

In this paper, we review the major areas of concern incare of patients with CKD, in whom the dual goals aredelay of progression to ESRD, and reduction of cardio-vascular risk. These areas include hypertension, use ofblockade of the renin-angiotensin system, anemia, lipidlowering therapy, calcium/phosphorus metabolism andsecondary hyperparathyroidism, and glycemic control.

Blood PressureCardiovasular disease is the leading cause of

mortality among CKD patients.5 Blood pressure controlboth reduces progression of CKD and reduces cardio-vascular mortality risk. In fact, blood pressure control inpatients without CKD can minimize age-related declinein GFR.6 The decline in GFR is directly related tosystolic pressure. The goals suggested by the Seventh Report of the

Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure for

CKD patients is 130/80. Unfortunately, according to theNational Health and Nutrition Examination Surey, only11 percent of treated patients are controlled at the levelof 130/85.7

Therapeutic lifestyle modifications should always beincluded in the management of hypertensive patients.Strategies with validated outcomes include sodiumrestriction to 2.4 g/d, regular aerobic exercise, theDASH diet, moderate weight reduction, reducedalcohol consumption, and smoking cessation.Many CKD patients have proteinuria, and blood

pressure therapy can include attention to this facet ofrenal damage. Angiotensin converting enzyme (ACE)inhibitor therapy can control blood pressure, reduceproteinuria, and slow progression of CKD. Angiotensinreceptor blocking drugs (ARB) have demonstratedsimilar benefit. So far, ARBs have not been shown toretain any significant advantage over ACE inhibitors. Hypertension in CKD patients is often complicated,

and frequently presents with pressures greater than20/10 above goal. Thus, many CKD patients requires aminimum of two antihypertensive agents. Because saltand water retention often accompany CKD, diureticsshould be a part of blood pressure management. Thiazide diuretics lose therapeutic effect at lower

levels of GFR, so that by the time patients are in thelower range of Stage 3, loop blockers should be usedrather than thiazides. Higher doses are often needed todeliver adequate amount of drug to its therapeutic site.Oral absorption of furosemide is quite variable in CKD,ranging from 10 percent to 100 percent, and half-life isrelatively short. Absorption of bumetanide and torsemide are greater

and more predictable (80-100 percent), and the latterhas a significantly longer half-life. Potassium sparingdiuretics should be used with caution in CKD, as theydo not provide robust natriuresis, and may causeserious hyperkalemia.Although beta blockers are often indicated for

comorbidities that are common among the CKDpopulation (e.g., post-MI, CHF), they are perhapsunderutilized in CKD8,9,10 because of their variable toler-ability. They function effectively as antihypertensives,and they may ameliorate the sympathetic hyperactivitypresent in CKD, which can aggravate the progression ofhypertensive nephropathy. Beta blockers have beenshown to decrease mortality in heart failure, the leadingcause of death in the first year of starting dialysis. On the other hand, beta blockers may impair glucose

delivery, impair insulin resistance, and worsen lipidprofiles. These effects may be attenuated by alpha-1

For many years the Cockcroft-Gault equation has been used to estimate

creatinine clearance at the bedside. This method is inaccurate at the

extremes of renal function, the extremes of age, and when comparing

individuals of different race or different muscle mass.

Table 1. Stages of CKD

Stage Description GFR (ml/min/1.73m2)

1 Kidney damage, normal or GFR >90

2 Kidney damage, mild � GFR 60-89

3 Moderate decrease in GFR 30-59

4 Severe decrease in GFR 15-29

5 Kidney failure <15 or dialysis



antagonism, which produces opposite effects.Nonselective beta blockers are also more likely topromote hyperkalemia. There are some data tosuggest that beta blockers can diminsh free-radical mediated oxidative stress, and thus reducemicroalbuminuria.8

Some beta blockers must be dose-adjusted forrenal disease; for instance, atenolol should have a50-75 percent dose reduction. The beta-1 selec-tive drugs atenolol and metoprolol have beenmost extensively studied in patients with renaldisease. Metoprolol does not require any doseadjustment in renal failure. Labetalol and carvedilol are the two beta

blockers with alpha-1 antagonism activity. Studieswith labetalol in CKD are few, with smallnumbers of subjects, and have conflicting dataregarding renal blood flow effects. Labetalol isdialyzed and is associated with hyperkalemia.Carvedilol is somewhat better studied in renaldisease and clearly attenuates albuminuria, hasless hyperkalemia, produces no change in theserum creatinine level, and is not dialyzed. The renoprotective effects of ACEIs and beta

blockers in CKD has been studied. The rate ofGFR decline and albuminuria progression is lesswith ACEIs than with either metoprolol oratenolol.11-15 The effects of these drugs to modifythe course of CKD or proteinuria seems to beattenuated in African Americans with hyperten-sive nephropathy, as evidenced by the African-American Study of KidneyDisease and Hypertensiontrial.16

Both classes of calciumchannel blockers (dihydropy-ridines and non-dihydropy-ridines) can be used safely inCKD without dose adjust-ments. They decrease periph-eral vascular resistance and have good absorption.When used in conjunction with an ACEI or anARB, they may enhance renoprotection, thoughthe individual agents have variable effects onproteinuria. Many patients with CKD have particularly

resistant hypertension, and require multiple drugs.Second and third line agents that can be useful inCKD include the centrally acting alpha-2 agonistclonidine, peripheral acting alpha-1 blockers likeprazosin, doxazosin, and terazosin, and the directvasodilators like hydralazine and minoxidil. Theseagents may be necessary to control blood pressurein resistant hypertension.

Proteinuria Proteinuria can be glomerular or tubular in

origin, or, the result of overproduction. Persistentproteinuria is an independent risk factor forcardiovascular disease, and its presence correlateswith the progression of chronic kidney disease. Indiabetes, microalbuminuria is an early indicator ofnephropathy. The most convenient way toquantify asymptomatic proteinuria is the spoturine protein to creatinine ratio, which serves as a

good surrogate for 24h protein excretionin grams/day.17

Microalbuminuria, most oftenmonitored for diabetic nephropathy, isdefined as the presence of 30-300mg/day,whereas proteinuria is defined by thepresence of >300 mg protein/24h. Thepresence of proteinuria is not only anindicator of CKD, but it is also thought toplay a role in perpetuating CKD. TheKidney Disease Outcomes Quality Initia-tive (K/DOQI) goals for proteinuria areto reduce it to less than 500-1000mg/day.The treatment of proteinuria in chronickidney disease will be discussed here.It is well established that the use of

ACEIs minimizes the progression ofproteinuria in CKD, especially in diabeticnephropathy.17 The mechanism is thoughtto be two-fold, by reducing intra-glomerular pressure and also possibly byenancing podocyte permselectivity. Low sodiumdiets enhance this reduction in proteinuria. A recent meta-analysis addressed the use of

ACEIs versus ARBs to reduce proteinuria inCKD.18 The findings suggest equivalent reduc-tion in proteinuria between ACEIs and ARBs,but a greater reduction in proteinuria from acombination of the two. Even patients withadvanced CKD, e.g. Stage IV, should be startedon ACEI or ARB therapy. The drugs should be

started at low doses and titrated upward,monitoring within the first week for the develop-ment of hyperkalemia or a sharp increase inserum creatinine. Small increases in creatinine aretolerated, even expected, indicating the usualmechanism of the drug.Statins have been proposed to halt the

progression of CKD. This was based on severalpost hoc analyses of studies that did not includeCKD progression as a primary outcome.Currently, there is not enough evidence tosupport the use of statins specifically fordecreasing CKD progression. Importantly, CKDpatients are candidates for statin therapy toreduce cardiovascular risk. With respect to dietary protein restriction and

the progression of renal disease, the MDRDstudy is the largest trial to date, studying 585patients. After an initial sharp decline in GFRassociated with the low protein diet within thefirst four months, only a very modest long termreduction in GFR decline was sustained(2.8mL/min/year), compared to 3.9mL/min/yearin the control group.19 Some have expressedconcern that protein restriction might increase

the risk of malnutrition as CKD progresses. Theuse of protein restricted diets has waned since theadvent of ACEIs and ARBs.

AnemiaNormocytic normochromic anemia typically

begins as GFR falls below 60mL/min. Decreasederythropoietin production is the primary cause. Inaddition, red cell life span is diminished; this maybe linked to elevated blood viscosity.20 All CKDStage III, IV, and V patients should be screened

for anemia. Anemia evaluation

includes red cell indices,reticulocyte count, iron,percent saturation oftransferrin, and ferritin,and exclusion of anemiafrom another cause, forinstance, GI bleeding or

deficiency of folate or B-12. If iron deficiency isdetected, it should be further evaluated and treated.Long standing anemia can cause increased LVmass, which aggravates cardiovascular risk. Once iron is replete, the mainstay of treat-

ment for CKD anemia is an erythropoiesisstimulating agent (ESA), such as erythropoietinalpha, beta, or darbepoietin. Ongoing ironsupplementation is usually required to avoid afunctional iron deficiency because of defectiveiron transport in CKD. Oral iron can be supplied as ferrous sulfate

325mg (65mg elemental) TID. Goals for irontherapy are to maintain the percent transferrinsaturation above 20 and the ferritin above100ng/mL. The target Hb level for CKD wasre-evaluated in the 2006 KDOQI recommen-dations. The current target is greater than11g/dL but no higher than 13g/dL.21 Neitherobservational data or results from randomizedcontrolled trials provide evidence to supportthe idea that hemoglobin should be normalizedin advanced CKD.22

Many patients with CKD have particularly resistant hypertension, and

require multiple drugs. Second and third line agents that can be useful in

CKD include the centrally acting alpha-2 agonist clonidine, peripheral act-

ing alpha-1 blockers like prazosin, doxazosin, and terazosin, and the direct

vasodilators like hydralazine and minoxidil.


Reducing Cardiovascular Risk and ESRD In Chronic Kidney Disease Patients



LipidsThe majority of CKD patients die from cardiovas-

cular disease. For this reason alone, reducing cardiovas-cular risk is paramount in this population. Althoughelevated LDL has been shown to promote glomeru-losclerosis in rats,23 this has not been translated tohuman studies. Post-hoc analyses have, however, linkeddyslipidemia to a decline in GFR. There are some datato suggest that lipid control may curb GFR decline.22

While there is no robust evidence that improved lipidcontrol reduces CKD progression, CKD is a coronaryheart disease (CHD) risk equivalent and these patientsshould be screened and treated aggressively.24,25,26

Dyslipidemia with elevated LDL is most commonamong the diabetic CKD population. In nondiabeticCKD patients, hypertriglyceridemia is almost universalbelow a GFR of 30mL/min.24 This is most likely dueto low lipoprotein lipase activity.23 Triglycerides arealso elevated in transplant patients secondary toimmunosupressant therapy. Nephrotic CKD patientstypically have elevated total cholesterol, LDL, andtriglycerides secondary to dimished catabolism of LDLand triglycerides.25

Reasonable goals for LDL in CKD have beenextrapolated from the ATP-III data. For patients withCKD, LDL<100mg/dL is recommended; for patientswith diabetes and CKD, the more stringent goal of<70mg/dL is recommended.25,26 The treatment approachis similar to non-CKD patients, with dietary and thera-peutic lifestyle modifications serving as a necessarystarting point. Statins are the most effective class of drugs to achieve

LDL goals in CKD. Dose reduction by 50 percent isrecommended in CKD Stage 4 for lovastatin, fluvastatinand simvastatin24; in practice, this might not be possiblefor these particular statins without sacrificing thera-peutic efficacy. P450 inhibitors will elevate serum levelsof the statin and caution should be used whenprescribing such drugs as fibrates, nicotinic acid,warfarin, SSRIs, non-dihydropyridine calcium channelblockers, azoles, and macrolides. For patients inadequately controlled on a statin alone,

the addition of a bile acid sequestrant is probably thebest choice in CKD, as long as the triglycerides are notelevated. The phosphate binder sevelamer has beendocumented to reduce LDL in CKD patients.28,29

Triglyceride control is best achieved after TLC witheither a fibrate or niacin. Niacin has the additionalbenefit of reducing phosphorus in CKD late Stage IVand V patients.30 Gemfibrozil is the least likely of theseagents to affect BUN and creatinine, and can be usedwithout dose alteration throughout the range of CKD.Fish oil reduces triglycerides in the general population,but has not been specifically studied in CKD.

Calcium, Phosphorus, Bone andSecondary HyperparathyroidismThe development of secondary hyperparathyroidism

in CKD is insidious. It is dependent on the interplaybetween hyperphosphatemia, hypocalcemia, andcalcitriol (1,25-dihydroxycholecalciferol). Reduction inGFR leads to hyperphosphatemia that increases theproduction and release of parathyroid hormone

(iPTH). The reduced ability of the failing kidney toactivate Vitamin D into calcitriol also elevates serumiPTH via poor calcium absorption and decreased PTHtranscription. Elevated PTH results in a variety ofbone mineral diseases. Monitoring for the development of secondary hyper-

parathyroidism should begin in CKD III. Guidelines forthe treatment of PTH include specific GFR—or CKDstage--related goals. Achieving iPTH lower than150pg/mL in ESRD is not recommended, as this canpromote adynamic bone disease. One parameter oftreatment is the calcium-phosphate product; in ESRD,this should be less than 55 mg2/dL2. An elevated Ca-Phos product is associated with calciphylaxis, myopathy,and vascular calcifications. The treatment of secondary hyperparathyroidism has

evolved with the advent of non-metallic basedphosphate binders and the novel medication cinacalcet.Dietary modifications to reduce phosphate intake gener-ally result in further protein malnutrition in this alreadypopulation whose nutritional status is already compro-mised; but the intake of no more than 800mgphosphorus is reasonable. The two most common non-calcium based phosphate

binders are sevelamer and lanthanum. Neither promotesthe vascular calcifications seen with calcium basedphosphate binders. Nutritional Vitamin D deficiency(25(OH)-Vitamin D, calcidiol) is common in CKD, andthe administration of ergocalciferol to replete calcidiol isincreasingly popular. Randomized controlled trials on thedevelopment of bone mineral disease are needed toevaluate the efficacy of this approach. The use of Vitamin D3 analogs is generally reserved

for patients with very high iPTH, and they are adminis-tered with close attention to the calcium-phosphateproduct. The available Vitamin D3 analogs includecalcitriol, paracalcitol, and doxercalciferol. The latter twoare less likely to cause hypercalcemia than calcitriol.

The treatment of secondary

hyperparathyroidism has

evolved with the advent of

non-metallic based phosphate

binders and the novel medica-

tion cinacalcet.

continued from page 7==



Dosing schedules vary and must be adjusted,and vitamin D analogs can be used concomitantlywith calcimimetic therapy. A novel calcimimeticmedication, cinacalcet, actually sensitizes theparathyroid gland receptors to calcium. This hasexcellent efficacy in reducing both the iPTH andCa-Phos product, and is indicated in patientswith iPTH >300pg/nL.31 Attention to secondaryhyperparathyroidism and nutritional Vitamin Ddeficiency is an integral part of managing CKD.

Glycemic ControlCKD is associated with altered insulin and

glucose metabolism. Insulin resistance is seen inearlier stages of CKD. With the development ofuremia, peripheral skeletal muscle uptake of glucoseis impaired, resulting in hyperglycemia.32 This canbe mitigated or reversed with aerobic exercise. Inaddition, metabolic acidosis and calcitriol deficiencyboth reduce circulating insulin.33,34

As GFR declines, the clearance of insulindiminishes, anorexia and malnutrition are morecommon, and patients may have a greatertendency toward hypoglycemia. Insulin require-ments change again when patients are placed onrenal replacement therapy. In diabetics withoutCKD, tight glycemic control has been shown toreduce the development of nephropathy. (34, 35)

The use of metformin in patients with a GFRbelow 60mL/min may increase the risk of lacticacidosis. Additionally, the metabolism of sulfony-lureas is reduced in CKD; therefore, it is prudent todose these drugs conservatively. Of the sulfony-lureas, glipizde is primarily metabolized throughthe liver and has the least active metabolite. Insulindoses are not usually adjusted until CKD III, whena GFR below 50mL/min generally demands a 25-50 percent reduction in insulin. The initiation ofdialysis enhances insulin clearance, demandingattention to insulin adjustment. Attention to nutri-tion, exercise, oral and insulin therapy is necessaryto maintain a hemoglobin A1C of less than 7percent in CKD patients.

SummaryThe epidemic of CKD and the progression to

ESRD threaten to become economicallyoverwhelming in the coming decades. Stemmingthis tide requires the cooperative efforts ofprimary care physicians and nephrologists. Andyet, “a National Institute of Health consensusconference reported that only 20-25 percent ofpatients were referred to a nephrologist prior toonset of ESRD”.35

Benefits of timely intervention in CKD patientsmay include the following: slowing progression to

ESRD, improved nutrition, reduced rate ofmetabolic complications, and modification ofcardiovascular risk factors. And if patients doprogress to ESRD, it is hoped that placement ofdialysis access can be done in a timely manner,since fistula use lowers dialysis mortality; and thattransplant rate will be increased. Most importantly, timely cooperation between

primary care physician and nephrologist translatesto improved survival. “Patients who saw anephrologist [for the first time] less than 90 daysbefore onset of dialysis had a 36 percent greatermortality rate compared with those who had theirfirst nephrology visit earlier”.36 It is the jointresponsibility of the primary care physician andthe nephrologist to work together to improve thisalarming mortality statistics. �

Dr. Snyder is a 1980 graduate of PhiladelphiaCollege of Osteopathic Medicine. He is board certifiedin Internal Medicine and Nephrology, and is chair ofInternal Medicine at Nova Southeastern UniversityCollege of Osteopathic Medicine. Dr. Thomas is a2006 graduate of Des Moines University College ofOsteopathic Medicine, and is currently a resident inInternal Medicine at Mt. Sinai Medical Center,Maimi Beach, FL.

References1. http://www.usrds.org/2007/ref/K_econ_07.pdf.2. Levey AS et al, Kidney International, 2005, 67:2089-21003. Levey AS et al, Ann Intern Med, 2003;139-1474. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm 5. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National

Committee on Prevention, Detection, Evaluation, and Treatment of Hypertension.Hypertension. 2003;42:1206-52.

6. Bakris GL, Williams M, Dworkin L, Elliott WJ, Epstein M, Toto R, et al. Preservingrenal function in adults with hypertension and diabetes: A consensus approach. NationalKidney Foundation Hypertension and Diabetes Executive Committees Working Group.Am J Kidney Dis 2000;36:646-61.175.

7. Coresh J, Wei GL, McQuillan G, Brancati FL, Levey AS, Jones C, et al. Prevalence ofhigh blood pressure and elevated serum creatinine level in the United States: Findingsfrom the Third National Health and Nutrition Examination Survey (1988-1994). ArchIntern Med 2001;161:1207-16.

8. Bakris GL, Hart P, Ritz E, Beta Blockers in the Management of Chronic Kidney Disease.Kidney Int. 2006;70(11):1905-13.

9. Bakris GL. Role for beta-blockers in the management of diabetic kidney disease. Am JHypertens 2003; 16: 7S-12S.

10. Wright RS, Reeder GS, Herzog CA et al. Acute myocardial infarction and renaldysfunction: a high-risk combination. Ann Intern Med 2002; 137: 563-570.

11. Bjorck S, Mulec H, Johnsen SA et al. Renal protective effect of enalapril in diabeticnephropathy. BMJ 1992; 304: 339-343.

12. Hannedouche T, Landais P, Goldfarb B et al. Randomised controlled trial of enalapril andbeta blockers in non-diabetic chronic renal failure. BMJ 1994; 309: 833-837.

13. Lacourciere Y, Nadeau A, Poirier L et al. Captopril or conventional therapy inhypertensive type II diabetics. Three-year analysis. Hypertension 1993; 21: 786-794.

14. Apperloo AJ, de Zeeuw D, Sluiter HE et al. Differential effects of enalapril and atenololon proteinuria and renal haemodynamics in non-diabetic renal disease. BMJ 1991; 303:821-824.

15. Himmelmann A, Hansson L, Hansson BG et al. ACE inhibition preserves renal functionbetter than beta-blockade in the treatment of essential hypertension. Blood Press 1995; 4:85-90.

16. Douglas J, Greene TH, Toto RD, Bakris GL, Norris KC, Luke RG. The African-American Study of Kidney Disease and Hypertension (AASK Trial). J Am Soc Nephrol.2002;13:131P.

17. Schwab SJ, Christensen RL, Dougherty K, Klahr S. Quantitation of proteinuria by theuse of protein-to-creatinine ratio in single urine samples. Arch Intern Med.1987;147:943-944.

18. Kunz R, Friedrick C, Wolbers M, and Mann, JFE. Meta-analysis: Effect of Monotherapyand Combination Therapy with Inhibitors of the Renin-angiotensin System onProteinuria in Renal Disease. annals of internal medicine jan 1 2008; 48(1):30-48.

19. Klahr S; Levey AS; Beck GJ; Caggiula AW; Hunsicker L; Kusek JW; Striker G forModification of Diet in Renal Disease Study Group.The effects of dietary proteinrestriction and blood-pressure control on the progression of chronic renal disease. N EnglJ Med 1994 Mar 31;330(13):877-84.

20. Brimble KS, McFarlane A, et al. Effect of Chronic Kidney Disease on Red Blood CellRheology. Clinical Hemorheology and Microcirculation, 2006; 34:411-420.

21. Constantini E, ed, KEEP Annual Data Report 2006. Anemia and CKD. Am J KidneyDis, 2007. 50(Suppl 3):S79-S86.471-530, 2007

22. Singh AK, Szczech L, Tang KL, et al. Correction of Anemia with Epoetin Alfa inChronic Kidney Disease. N Engl J Med 2006;355:2085-98.

23. Diamond JR, Karnovsky MJ. Exacerbation of chronic aminonucleoside nephrosis bydietary cholesterol supplementation. Kidney International, 1987; 32:671-7.

24. Fried LF, Orchard TJ, Kasiske BL. Effect of Lipid Reduction on the Progression of RenalDisease: A Meta-analysis. Kidney International 2001;59:260-269.

25. Keane, WF. Lipids and the Kidney. Kidney International 1994, 46:910-920. 26. Sandhu S, Wiebe N, et al. Statins for Improving Renal Outcomes: A Meta-analysis. J Am

Soc Nephrol 2006, 17: 2006-2016.27. Grundy SM, Cleeman JI, Merz CNB, Brewer HB Jr, Clark LT, Hunninghake DB,

Pasternak RC, Smith SC Jr, Stone NJ for the Coordinating Committee of the NationalCholesterol Education Program: Implications of recent clinical trials for the NationalCholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol44: 720 –732, 2004

28. Chertow GM, Burke SK, Lazarus JM, et al. Poly[allylamine hydrochloride] (RenaGel): Anoncalcemic phosphate binder for the treatment of hyperphosphatemia in chronic renalfailure. Am J Kidney Dis, 1997, 29;66-71

29. Chertow GM, Burke SK, Raggi P. Sevelamer attenuates the progression of coronary andaortic calcification in hemodialysis patients. Kidney Int, 2002, 62;245-252.

30. Takahashi Y, Tanaka A, et al. Nicotinamide suppresses hyperphosphatemia inhemodialysis patients. Kidney International, 2004; 65:1099-1104.

31. Lindberg, JS, Culleton, B, Wong, G, et al. Cinacalcet HCl, an Oral Calcimimetic Agentfor the Treatment of Secondary Hyperparathyroidism in Hemodialysis and PeritonealDialysis: A Randomized, Double-Blind, Multicenter Study. J Am Soc Nephrol 2005;16:800-7.

32. DeFronzo RA, Alvestrand A, et al. Insulin resistance in uremia. J Clin Invest, 1981; 67:563–568.

33. Mak RHK, Effect of metabolic acidosis on insulin action and secretion in uremia. KidneyInternational, 1998; 54: 603–607.

34. Kautzky-Willer A, Pacini G, et al. Intravenous calcitriol normalizes insulin sensitivity inuremic patients. Kidney International, 1995; 47: 200–206.

35. The Diabetes Control and Complications Trial Research Group. The effect of intensivetreatment of diabetes on the development and progression of long-term complications ininsulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.

36. Genuth S, Eastman R, Kahn R, et al. Implications of the United Kingdom prospectivediabetes study. Diabetes Care 2003;26(suppl 1):S28-32.

37. Diaz-Buxo J, The importance of pre-ESRD education and early nephrological care inperitoneal dialysis selection and outcome. Perit Dial Int, 1998; 18:363-5.

38. Winkelmayer WC, Owen WF, et al. A propensity of late versus early nephrologist referraland mortality on dialysis. J Am Soc Nephrol, 2003; 14:486-492.

1 0 O S T E O PAT H I C FA M I LY P H Y S I C I A N N EW S A P R I L 2 0 0 8

In the worldwide INTER-HEART study of patients from 52countries, nine potentially modifi-able factors accounted for over 90percent of the attributable risk of afirst heart attack.2 These factorsinclude smoking, dyslipidemia,hypertension, diabetes, abdominalobesity, psychosocial factors, dailyconsumption of fruits and vegeta-bles, alcohol consumption, andphysical activity.Fortunately, there are several

ways to reduce the chances of suf-fering from heart disease: maintaina healthy weight and normal bloodpressure, avoid smoking, exerciseregularly, eat plenty of fruits andvegetables, get tested and treated(if necessary) for diabetes, andabnormal cholesterol and triglyc-erides. It is important for patientsto work together along with theirprimary care provider to achievethese goals. An osteopathic family physician

utilizes a holistic approach toachieve optimal health so that thebody and mind are healthy and areable to be cared for by promotingideal blood and lymphatic flow. Tominimize the chance of heart dis-ease, one should have regularlyscheduled preventive exams thatinclude risk factor modification, lab-work, and osteopathic manipulation. Many causes of heart disease are

preventable and thus it is crucial tomake these lifestyle changes to pre-vent the leading cause of death anddisability in the United States. TheNurses’ Health Study (2000) foundthat among women, maintaining adesirable body weight, eating ahealthy diet, performing regularexercise, and not smoking couldaccount for an 84 percent reductionin their cardiovascular risk.3

U.S. Mortality fromCoronary Heart Disease The most powerful and the most

preventable risk factor for heart dis-ease is smoking, according toMayoClinic.com.4 One must avoidall tobacco products. One year afterquitting, the risk of heart attack anddeath from chronic heart disease isreduced by one-half, and after sever-al years begins to approach that ofnonsmokers.5 The nicotine in ciga-rette smoke makes the heart workharder by constricting blood vesselsand increasing heart rate and blood

pressure. The carbon monoxide incigarette smoke replaces some of theoxygen in the blood. This increasesthe blood pressure by forcing theheart to work harder to supply oxy-gen. Tobacco contains 4,800 chemi-cals, many of which cause athero-sclerosis and heart disease.4 Second-hand smoke, especially over a longperiod of time, can carry the samerisks due to the inhalation of thesame harmful chemicals. The good news, though, is that

when someone quits smoking, theirrisk of heart disease drops dramati-cally within just one year.4 Manytherapies are currently available tohelp one stop smoking including arelatively new prescription aid calledvarenicline (Chantix) that mimicsnicotine receptor action in the brainwithout having to ingest the harm-ful nicotine chemical.Physical activity is imperative.

Federal guidelines recommend “atleast 30 to 60 minutes of moderatelyintense physical activity most daysof the week.”4 People don’t have toexercise strenuously; although, con-stant aerobic activity that produces asweat is recommended. Not onlydoes physical activity directly reducethe chance of heart disease, but itgreatly assists in modifying otherrisk factors such as weight reduc-tion, blood pressure control, andstress reduction.A heart-healthy diet is the next

step. Consistently eating a diet richin fruits, vegetables, whole grains,and low-fat dairy products can pro-tect the heart.6 Limiting the intakeof certain fats is crucial. Saturatedfats and trans-fats increase the riskof heart disease by increasing cho-lesterol levels. Trans-fat may beworse than saturated fat because

trans-fat raises LDL (bad choles-terol) and lowers HDL (good cholesterol). Saturated fats includebeef, butter, cheese, and milk. Themore-maligned trans-fats are foundin deep fried fast foods, bakeryproducts, packaged snack foods, and margarine. Substantial evidence from the

Journal of the American MedicalAssociation ( JAMA) indicates thatdiets using nonhydrogenated unsat-urated fats as the predominant formof dietary fat, whole grains as themain form of carbohydrates, anabundance of fruits and vegetables,and adequate omage-3 fatty acidscan offer significant protectionagainst CHD.6 Alcohol in modera-tion can protect the heart althoughalcohol in excess can be hazardousto the heart. The average maleshould drink no more than twodrinks a day; the average femaleshould drink no more than onedrink a day.A healthy weight must be main-

tained. In order to find out one’shealthy weight, he or she can calcu-late their body mass index (BMI). A BMI greater than 25 is associatedwith a higher risk of heart disease.BMIs do have drawbacks in thatmuscle weighs more than fat andmay falsely elevate one’s BMI. Inthis case, waist measurement is agood indicator. A waist size greaterthan 40 inches in males and 35inches in females is associated withhigher risk of heart disease.6

Furthermore, weight reductionshave been proven to lower bloodpressure and cholesterol whiledecreasing the risk of diabetes.A high-fiber diet has many bene-

fits that include lowering blood cholesterol and controlling blood


Heart Disease Preventioncontinued from page 1==

In the worldwide INTERHEART

study of patients from 52

countries, nine potentially

modifiable factors accounted

for over 90 percent of the

attributable risk of a first

heart attack.2 These factors

include smoking, dyslipi-

demia, hypertension, dia-

betes, abdominal obesity,

psychosocial factors, daily

consumption of fruits and

vegetables, alcohol consump-

tion, and physical activity.

O S T E O PAT H I C FA M I LY P H Y S I C I A N N EW S A P R I L 2 0 0 8 1 1


sugar levels. Soluble fiber found inbeans, oats, flaxseed and oat bran mayhelp lower LDL cholesterol. Also, sol-uble fiber can slow the absorption ofsugar, which for people with diabetescan help improve blood sugar levels.Men 50 years old or younger shouldreceive at least 38 grams of fiber a day,men older than 50 should receive 30grams a day, women 50 years oryounger should receive 25 grams a dayand women older than 50 shouldreceive 21 grams a day.6 Fiber can befound in grains, whole-wheat prod-ucts, fruits, vegetables, beans, legumes,nuts and seeds.Antioxidant vitamins have been a

focus of research in cardiovasculardisease. At this time, the AmericanHeart Association does not recom-mend using antioxidant vitamin sup-plements until more complete dataare available. The scientific evidencesupports a diet high in food sourcesof antioxidants and other heart-pro-tecting nutrients, such as fruits, veg-etables, whole grains and nuts insteadof antioxidant supplements to reducerisk of CVD. Some recent studieshave even shown harmful effectsfrom antioxidant supplements.6

Minimizing stress also appears toreduce heart disease. The linkbetween stress and heart disease isnot completely clear, but what isknown is that stress accelerates theheart rate. People with heart diseaseare more likely to have a heartattack during times of stress.7

Minimizing stress is included in theholistic care of medicine whichincorporates the integrated care ofmind and body.Nuclear radiographic tests also

are an aid in preventing heart dis-ease. Nuclear stress tests can identifyareas of the heart that are not get-ting optimally oxygenated. This canpredict cardiac events and thusenable a patient to undergo proce-dures to open diseased coronary ves-sels before harmful events occur.Also, on the frontiers of medicineare CT and MRI scanning tech-niques that directly visualize coro-

nary vessels and can measure block-ages and calcifications that maycause heart disease.Medicines can also treat heart

disease. The U.S. Food and DrugAdministration recognizes aspirin,with its anti-clotting abilities, as safeand effective in helping to lower therisk of a second heart attack. TheAmerican Heart Association recom-mends low-dose aspirin (75-160mg/day) in people at higher riskof coronary heart disease.7

Angiotensin-converting enzyme(ACE) inhibitors help the heartpump blood better, and beta block-ers slow the heart down. Nitratesand calcium channel blockers relaxblood vessels and relieve chest pain.Diuretics decrease fluid in the body.Patients should carefully reviewtheir medical history with their fam-ily physicians to determine whichmedicines are most appropriate forimproving their health.Angioplasty and stents are an

invasive way to open diseased vesselsin the heart. Angioplasty is the inser-tion of a balloon to widen a vesseland a stent may be placed to hold thevessel open. In 2003, drug-coatedstents were first used with the goal ofreducing the risk that the artery willre-clog. Coronary bypass is per-formed to replace a diseased vessel inthe heart with another vessel in thebody that is free from atheroscleroticdisease. These invasive procedures areperformed once the above risk factormodification has failed, and heartdisease has taken hold.Studies have shown that even a

“splurge” of saturated fat can causeheart disease. The Journal ofAmerican Cardiology reported thatwhen study participants ate just onepiece of high-fat carrot cake anddrank a milkshake, the ability oftheir arteries to accommodateincreased blood flow was dimin-ished.8 The sudden boost in what’sknown as saturated fat prevented“good” cholesterol, or HDL, fromdoing its job, which is to protect theinner lining of the arteries from

inflammatory agents that promotethe build-up of fatty plaques.8 Theeffects may be temporary. However,there is still a concern because theeffect may recur each time a personeats a high-fat meal.High levels of “good” HDL cho-

lesterol protect against heart diseaseand stroke no matter what the bloodlevels of “bad” LDL cholesterol,according to a new study in the NewEngland Journal of Medicine.9 In amajor trial, the incidence of heartattack, stroke, and other cardiovascu-lar problems was 40 percent lower inthe one-fifth of participants who hadthe highest HDL cholesterol levels,regardless of their LDL cholesterollevels.9 A medication that increasesHDL would likely greatly decreaseheart diseases according to this data.In 2006, Pfizer withdrew its HDL-increasing medication Torcetrapibbecause patients who took the medi-cine had a higher death rate.Other lab tests are available to

assess the risk of heart disease. Onetest detects homocysteine, a proteinthat may be better than cholesterolfor predicting heart disease andstroke. Lipoprotein a, Lp(a), is simi-lar to LDL but does not respond todiet, exercise, and medications.Lp(a) seems to be a marker ofgenetic disease and may show whichpatients are candidates for moreaggressive lipid-lowering therapy. Another test is hypersensitive C-

reactive protein (hsCRP) that may

predict a coronary event even inpatients having normal cholesterollevels. These different markers arecurrently speculative and the lipidprofile, fasting glucose, and triglyc-erides remain the gold-standard forassessing the risk of heart disease.Studies of patients with CHD sug-gest that serum triglycerides are anindependent predictor of risk.10

Regular health screenings withan osteopathic family physician areimperative in accomplishing theabove goals. High blood pressureand high cholesterol can damagethe heart but without getting thoselevels tested, one would not knowthey are elevated. Data from theAmerican Heart Association statesthat about 38 percent of peoplewho experience a heart attack in agiven year die from it.11 Thus, pre-vention of heart disease is crucial. Regular preventive exams are

economical in addition to the posi-tive health benefits they provide. Acardiac catheterization or bypass cancost tens of thousands of dollars ormore depending if hospitalization isrequired. Thus, regularly scheduledpreventive exams can allow a personto enjoy many more healthy andactive years. �

Dr. Felber is a 2005 graduate ofPhiladelphia College of OsteopathicMedicine. He is currently a third yearfamily medicine resident at FrankfordHospitals in Philadelphia, Pennsylvania.

References:1. The Center for Disease Control. Deaths: Final Data for 2004, Table 12.Http://www.cdc.gov/nchs/fastats/deaths.htm.

2. Yusuf, S, Hawken, S, Ounpuu, S, et al. Effect of potentially modifiable risk factor associatedwith myocardial infraction in 52 countries (the INTERHEART study): case-control study.Lancet 2004; 364-937.

3. Stampfer, MJ, Hu, FB, Manson, JE, et al. Primary prevention of coronary heart disease inwomen through diet and lifestyle. N Engl J Med 2000; 343:16.

4. The Mayo Clinic.com. http://www.mayoclinic.com/print/heart-disease-prevention/WO00041/METHOD=print.

5. US Department of Health and Human Services. The health benefits of smoking cessation: areport of the Surgeon General. Rockville, Maryland, US Department of Health and HumanServices, 1990. DHHS Publication 90-8416.

6. Hu, F and Willet, W. Optimal Diets for Prevention of Coronary Heart Disease. The Journalof The American Medical Association. Vol.288, No. 20, November 2002.

7. Peason, TA, Blair, SN, Daniels, SR, et al. AHA Guidelines for Primary Prevention ofCardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to ComprehensiveRisk Reduction for Adult Patients Without Coronary or Other Atherosclerotic VascularDiseases. American Heart Association Science Advisory and Coordinating Committee.Circulation 2002; 106:388.

8. Nicholls, S, et al. Consumption of Saturated Fat Impairs the Anti-Inflammatory Propertiesof High-Density Lipoproteins and Endothelial Function. Journal of the American Collegeof Cardiology, 2006; 48:715-720.

9. Barter, P, et al. HDL Cholesterol, Very Low Levels of LDL Cholesterol, and CardiovascularEvents.” The New England Journal of Medicine. Vol 357:1301-1310, September 27, 2007.

10. Austin, MA, Hokanson, JE, Edwards, KL. Hypertriglyceridemia as a cardiovascular riskfactor. Am J. Cardiol 1998; 81:7B.

11. Http://www.americanheart.org/presenter.jhtml?identifier=4591. Accessed 12/14/07.


president’sP E R S P E C T I V E

Change and Commitmentcontinued from page 1==

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University. Lockport is a small, family-oriented

community that offers year-round outdoor activities andis truly a “Sportsman’s Paradise.”

Interested parties should e-mail their CVs to:[email protected], Ref # AFM4, or call

(800) 488-2240 for information. J-1 visa candidates

welcome to apply. E.O.E.

We will continue to develop new programs indivergent regions of our country where there aregrowing numbers of osteopathic physicians andwhere our graduating students desire to train.The Committee on Evaluation and Education isworking to develop new, innovative programsthat feature special emphasis tracks as well asopportunities for fellowships and CAQ’s,programs that our students and resident havetold us they desire.In addition to student and resident education

reform, the education of our practicing physi-cians will continue to be augmented. In additionto up-to-date, scientifically-valid CME, addedemphasis will be placed on educating all ourmembers on the systems of medical practice thatare evolving and that will affect their practicesand careers. Our programs should allow ourmembers to make informed choices concerningelectronic health systems, the medical homeconcept, quality and patient safety initiatives’ arebeing developed and will be presented both atour meetings and online. While we fight forpayment reform, we must ensure that ourmembers can maximize the systems in place atthis time.

Commitment to MessageA new Public Relations initiative is being devel-

oped this year to ensure that the American public aswell as the policy makers and payers of this countryare aware of not only what an osteopathic familyphysicians is, but also the value and contributionsprovided by our profession to the health andwellness of this country. The day of being“America’s best kept secret, the only uniquelyAmerican form of medical care” should not only beover, it is an embarrassment that it is present morethan 140 years after Dr. Still founded this successfuldiscipline of medicine. We are seeking to become more inclusive of all

osteopathic physicians, regardless of where theyelect to complete their graduate medical educa-tion. ACOFP’s Congress passed resolutionspetitioning the AOA to replace the currentsystem of recognition controlled by Resolutions42 and 56 with a system that makes the criteriafor becoming certified by the AOBFP seamless,consisting only of documentation that the physi-cian graduated from an osteopathic medicalschool and completed a family medicineresidency. The days of exclusion should be overforever, they were never right, they were neverjust and they were never in our best interest.

At the same time, we are working to recog-nize, celebrate, and become more inclusive of thegrowing diversity within our profession. Womenand minorities compose more than 60 percent ofour students and residents; in the near future theywill compose the majority of our profession aswell. We must seek to discover what theseprofessionals feel is of value that would encouragethem to join us and share their talents andcommitment with us. We must recognize that tosuccessfully recruit we must not only welcomethem to join, but encourage them and promotethem to assume leadership position as well.I view this year is one of promise more than it

is one of challenge. I promise you that the Boardwill work to meet the challenges while we seek tofulfill the promise. Our colleagues, our patientsand our families expect nothing less from us.Have a great spring and I hope to see many, if

not all of you, soon.

Osteopathically Yours,

Ronnie B. Martin, DO FACOFP [email protected]

Volunteer to be an ACOFP Preceptor!

Volunteer to be an ACOFPPreceptor to osteopathic

medical students.

To volunteer, visitacofp.org, log in, and clickon My Preceptor Profile.

Advocacy u Education u Leadership



Inverting Osteopathic FamilyPhysicians Approach to OsteoporosisBy Robert Zaid, DO

This is the second place winner of the2008 Namey/Burnett WritingAward. The Namey/Burnett WritingAward is implemented by theACOFP Preventive Medicine andMedical Preparedness Committee tohonor the best preventive medicinepapers submitted by osteopathic familypractice residents, interns, and osteo-pathic medical students.

Introduction

Osteoporosis is responsiblefor 1.5 million life alter-ing fractures a year in the

United States.1 Hip fractures areamong the most debilitating frac-ture related to osteoporosis andconsiderable resources are utilizedin treating these patients.Typically, high risk patientsincluding post-menopausalwomen are screened forOsteoporosis and treatment isgeared towards prevention ofbone loss. Often patients arediagnosed too late and wouldhave benefited from earlier inter-vention.Peak bone formation in males

and females occurs around 25years of age2, while women under-go accelerated bone loss atmenopause. The amount of bone formed prior to 25years of age has been shown to be directly relate to riskfor complications from osteoporosis later in life. In fact,bone mass increases progressively during childhood and40 percent of total bone mass is accumulated duringlater adolescence.3 Although most bone mass is accruedduring adolescence, family physicians expend most oftheir energy towards preventing bone loss in patientswho already have the disease. Children are capable ofabsorbing calcium from their diets more efficiently thanthe elderly. Instead of extracting calcium from their diet,the elderly will resorb calcium from their bones.2 Thesefacts may cause family physicians to rethink their focuswhen approaching osteoporosis.If family physicians implement measures targeting

habits that promote bone growth in childhood, wemay find that preventing bone loss in the future maybe less imperative.In considering treatment for osteoporosis, primary

prevention is as much if not more important than sec-ondary or tertiary prevention. Family physicians play acritical role in educating and promoting good lifestylechoices for youth while their bones are still forming andbefore bone loss begins.

Over the last several decades in the United States,children have been replacing caffeinated drinks for dairydrinks in their diets; playing video games instead ofbaseball, and many preteen children smoke cigarettes.All of these factors are contributing to decreased peakbone mass and studies have shown that bone mass inadolescents is related to risk of osteoporosis later in life.2

Family physicians should emphasize bone formationearly on, rather than relying on efforts to preserve bonelater in life.

Risk Factors (Modifiable)In order to be successful in preventing osteoporosis

family physicians must maintain a comprehensiveunderstanding of the risk factors that cause osteoporosis,affording particular attention to those that can bealtered. The modifiable risk factors for osteoporosis canbe divided into those that are metabolic and those thatare mechanical.

Metabolic Risk FactorsThe use of tobacco, caffeine, and alcohol can all cause

excretion of calcium from the urine. Additionally, exces-

If family physicians imple-

ment measures targeting

habits that promote bone

growth in childhood, we

may find that preventing

bone loss in the future may

be less imperative.

Second Place



sive intake of protein and phosphate can cause anegative calcium balance.5 Inadequate nutritioncoupled with low calcium intake early in life mayresult in a decreased peak bone mass.4 These fac-tors may be negated if appropriate calcium intakeor calcium supplementation is implemented.In contemporary American society, increased

consumption of soft drinks often replaces dairybeverages and this significantly affects bonestructure. These drinks will cause dieresis and lossof calcium from the urine, while providing high

amounts of phosphates that also promote calciumloss in the urine. Also, the absence of calciumrich dairy products in the diet compounds alsocontributes calcium deficiency.Decreased exposure to the sun can decrease

Vitamin D levels in the body that in turn cancause a decreased absorption of calcium in theblood. Parathyroid hormone is then secreted, andbone loss occurs to maintain calcium levels.5 Over

time this can have deleterious effects on bonestructure and can cause thinning of cortical bone.

Mechanical Risk FactorsAlthough bone metabolism relies on the total

body calcium loads, bone formation depends onweight bearing exercise. Bone becomes strongeras demand and work load increases. Low loadsallow for bone maintenance, high loads can causebones to become stronger and very high loads can

be deleterious.It is imperativethat childrenexercise andstay active.Gaininginsight of basicbone physiolo-

gy, it becomes clear that the cultural shift towardsenhanced and expanded video entertainment islikely to have significant impact on bone health.

PreventionAs explained earlier, children are much better

handlers of calcium than are adults. Due to thisfact, family physicians will obtain better results

for bone health if theyencourage calcium con-sumption at an earlyrather than later in life.Current recommenda-

tions for calcium intakecan be found in Table 1.Good sources of calciumcan be found in yogurt,milk, cheese, sardinesand salmon.1 If supple-mentation is needed,Calcium Citrate andGluconate are moreabsorbable than CalciumCarbonate. A more com-prehensive list of foodsrich in calcium can befound in Table 2.Required daily

amounts of vitamin Dcan be attained with sunexposure for 10 – 15minutes a day withoutsunscreen. Dietarysources of Vitamin D canbe found in liver, fish,Swiss cheese, egg yolkand fortified milk.

Amounts of caffeine should be limited andchildren should avoid soft drinks.Weight bearing exercises can be performed

fairly easily and do not require much effort. Someexamples of appropriate exercises include walking,jogging and dancing. Bone is extremely sensitiveto exercise and mechanical load. Low loads willmaintain bone, while high loads will remodelbone to withstand the new loads.1 Exercise for20 to 30 minutes a day, three days a week hasbeen recommended for adults, although no for-mal recommendation is available for children.

SummaryOsteoporosis is quite debilitating to both the

health of patients and with regard to the impacton the health care system. Patients lose quality oflife and have decreased function. Osteopathicfamily physicians have a unique opportunity toexamine patients and promote lifestyle choicesearly on that may benefit them before it is toolate. Often, providers target elderly patients whohave begun to show signs or have risk factors foracquiring osteoporosis. As educators, familyphysicians have the chance to teach patients goodhabits as children so that they develop the abilityto make good health choices throughout theirlives. Family physicians can encourage children toreduce the amount of caffeine, increase theamount of dairy products and to balance theamount of indoor activities with outdoor physicalactivities. By promoting bone growth in late ado-lescence, osteopathic family physicians may savepatients from a debilitating fall or bone fracturein the future, improving the quality and length oftheir lives. �

Dr Zaid, a graduate of Michigan State University, iscurrently a resident at Genesys Regional MedicalCenter in Grand Blanc, Michigan. He will beginpracticing in Novi, Michigan this August.

Gaining insight of basic bone physiology, it becomes clear that

the cultural shift towards enhanced and expanded video enter-

tainment is likely to have significant impact on bone health.

Table 1. RecommendedDaily Calcium Intake

Patient Population Mg

Children < 10 years 700

10-25 years 1,300

Adults 800

Pregnant Women 1,500

Lactating Women 2,000

Table 2. Foods High In Calcium

Food Serving Size Calcium Per Serving

Milk 1 cup 296 mg

Yogurt 1 cup 300-415 mg

Pudding 1 cup 250 mg

Ice Cream 1 cup 236 mg

Cottage Cheese (1% lowfat) 1 cup 120 mg

Cheddar Cheese 1 ounce 213 mg

American Cheese 1 ounce 198 mg

Turnip Greens 1 cup cooked 250 mg

Collard Greens 1 cup cooked 226 mg

White Beans 1 cup cooked 200 mg

Mustard Greens 1 cup cooked 125 mg

Broccoli 1 cup cooked 100 mg

Fortified Cereals 1 cup 1,000 mg

Fortified Orange Juice 1 cup 350 mg

Sardines (can with bones) 3 ounces 275 mg

Tofu (with calcium sulfate) 3 ounces 225 mg

Salmon 3 ounces 180 mg

Adapted from Rhode Island Osteoporosis Foundation

References:1. Curry, L; Hogstel, M. Osteoporosis: Education and awareness can make a difference,American Journal of Nursing, 102, January 2002, pp26-32.

2. Lane, J; Russell, L; Khan, S. Osteoporosis, Clinical Orthopedics, 372, March 2000, pp139-150.

3. Baroncelli, G; Bertelloni, S; Sodini, F. Osteoporosis in Children and Adolescents: Etiologyand Management, Pediatric Drugs, 7(5):295-323.

4. Raisz, L. Osteoporosis, Internal Medicine, Chapter 316, 1998.5. Wesite, Linus Pauling Institute, Micronutrient Research for Optimum Health, Phosphorus.



ePrescribing Tops the Hottest 2008 Health Information Technology Issue ListLearn more about the risks and benefits of ePrescribing, plus review recent survey results.

By Belinda Bombei

As globalcommunicationand business

continues to becomeincreasingly electronic,osteopathic familyphysicians have beenexamining ways to usetechnology toautomate the prescrip-tion writing process.ePrescribing enablesosteopathic familyphysicians to automatethe process of submit-ting patient prescrip-tions as opposed to writing them on paper.

Supported by President Bush, ePrescribing gainedinterest in 2005 with new regulations making it easierfor physicians to implement. In December 2007,Senator John Kerry, D-Massachusetts, and Representa-tive Allyson Schwartz, D-Pennsylvania, introducedlegislation that would require physicians servingMedicare beneficiaries to adopt electronic prescribing by2011 or face possible financial penalties.The bills, SB 2408 and HR 4296, also provide funding

to help physicians purchase computers and the softwareto use electronic prescribing. In addition, doctors wouldbe paid a one percent bonus for every claim theysubmitted that included an electronic prescription.

EPrescribing Statistics and InitiativesAccording to a just released February 2008 survey of

500 Detroit area physician practices that participated in

a three-year pilot program, a large majority of doctors,and their staff who use ePrescribing believe that itallows them to practice safer and better medicine. Haldy McIntosh & Associates for the SoutheasternMichigan ePrescribing Initiative (SEMI) conducted the survey.In addition, the SEMI survey results included:

• Three out of four prescribers believe strongly thatePrescribing improves safety for their patients.

• Seventy percent say it improves the quality of care.• One of the important benefits of ePrescribing cited byphysicians is the safety alerts that warn of potentiallyharmful drug-drug interactions and drug-allergy risksat the time of prescribing.

• Nearly 65 percent of physician ePrescribers reportedat least one incident of changing a prescription inresponse to a safety alert received through the system.1

ePrescribe FloridaA coordinated effort is under way in Florida to

motivate more physicians to use electronic prescribing.The initiative, called ePrescribe Florida, first gainedsupport from large health plans and influential providerorganizations. The Florida Osteopathic Medical Associ-ation (FOMA) serves as one of the influential providerorganizations, by serving on the ePrescribe FloridaAdvisory Council. Professional associations, such as FOMA, give

ePrescribe Florida some peer pressure it can use. Themission of ePrescribe Florida is to promote collaborativestate efforts toward successful adoption of e-prescribing.2

Nationwide Rankings of ePrescribing UsageFormer Speaker of the House Newt Gingrich

unveiled the first-ever nationwide ranking and analysisof ePrescribing activity across all 50 states andWashington, D.C., March 4, 2008 on Capitol Hill.

Image courtesy of Centers for Medicare and Medicaid.



Top 10 States Ranked byePrescribing Activity31. Massachusetts2. Rhode Island3. Nevada4. Delaware5. Michigan6. Maryland7. North Carolina8. Arizona9. Connecticut10. WashingtonTo view the complete state-ranking list, go to

www.surescripts.com/Safe-Rx.

BenefitsSupporters of ePrescribing like the fact that it

makes the prescription processing more efficient,

and it helps eliminate poorhandwriting errors. It also givespharmacies the ability to checkfor possible drug interactions,allergies, or other potentialhealth problems associated withnew prescriptions.ePrescribing offers many

great benefits for patients andphysicians, as well as pharmacies,health insurance providers,pharmaceuticals companies, andemployers. The benefits include:

• Efficiency of prescriptionprocessing.

• Eliminate lost prescriptions. • Improve patient safety andoverall quality of care.

• Reduce phone calls and callbacks topharmacies.

• Eliminate faxes to pharmacies.• Increase patient compliance.• Improve formulary adherence.• Increase patient convenience.• Offer true provider mobility.• Improve reporting ability.While the benefits are many, there are also

some challenges and risks involved with theadoption of ePrescribing.

ChallengesAs with any technology and electronic system,

ePrescribing faces challenges. One of the earlychallenges that delayed support for adoption ofePrescribing was concern over improper relations

between physicians and healthcare providers. Technology hardware and software is very

expensive and can be challenging osteopathicfamily physician offices to afford. This createssome ethical dilemmas as hospitals and pharma-cies often donate supplies to physicians.ePrescribing opponents suggest this creates unfaircompetition as the donated supplies may implyexpectations of business referrals when patientsneed prescriptions or care.Supporters have worked to impose regulations

that place caps on donation amounts and attemptto prohibit the potential for physicians receivingkickbacks or equipment donations for referrals. Technology is only as perfect as the people

that use it. Although ePrescribing is intended tohelp reduce errors, they are still possible. A physi-cian could potentially input the wrong informa-tion or amounts or make other errors incommunication. Recent surveys, such as the SEMI Initiative

research study, suggest that patients ultimatelygain through efficient prescription processing,reduced errors, and safer record management and checks. �

Belinda Bombei is the medical editor and writer fortweakMyWords.com and has over 14 years of experi-ence, including five years of experience editing andwriting for the osteopathic profession. She providessuggestions to transform osteopathic medical contentfrom good to outstanding, producing osteopathicfocused articles, websites, and eNewsletters worthy ofrecognition.

Image courtesy of of SureScripts.

References:1. Southeastern Michigan ePrescribing Initiative Research study. (2008). Retrieved February28, 2008 from http://www. prnewswire.com

2. ePrescribe Florida. Retrieved February 29, 2008 fromhttp://www.eprescribeflorida.com/aboutus.html

3. SureScripts. Retrieved March 4, 2008 from www.surescripts.com/Safe-Rx.

membershipM A T T E R S

ACOFP Welcomes New MembersThese individuals joined ACOFP between October 1, 2007 to January 1, 2008. Welcome to ACOFP!

Member City StateMark W. Tuccillo, DO Petersburg AKRandy D. Conover, DO Centerton ARDavid I. Bruce, DO Mesa AZE. Griffin Cipolla, DO Phoenix AZBhargavi Dineshkuma Joshi, DO Phoenix AZMichael F. Kleven, DO Peoria AZDouglas S. Anders, DO San Bernardino CAWilliam M. Carragher, III, DO Los Angeles CAKedy Y. Jao, DO La Mirada CASusan Elaine Mackintosh, DO Pomona CAKathryn D. Roth, DO Yucaipa CAKaren A. Davis, DO Lone Tree COTatiana Denning, DO Valrico FLKatie Erin Drake, DO Cape Coral FLScott C. Howell, DO Coral Springs FLRobert S. Oller, DO Cooper City FLLane R. Phillips, DO Lake Mary FLSy Rabins, DO Sarasota FL

Member City StateLori A. Colliton, DO Midland GAStephen C. Shannon, DO MPH Chevy Chase MDCharles R. Barker, Jr., DO Belding MICatherine A. Kroll, DO Gwinn MISherri Pam Rosenfeld, DO Livonia MIJolene J. Gracia, DO Wilson NCBruce D. Latham, DO Colebrook NHSean Fenton, DO New York NYMichael Petelis, DO Westbury NYThomas Lee, D.O. Akron OHRichard D. Brock, DO Purcell OKRandall Fryer, DO Portland ORLouis J. Gringeri, DO Newtown PABrian R Snyder, DO Richburg SCChristopher J. Imperial, DO College Station TXAdila N. Siddiqi, DO Grand Prairie TXKeith K. Ly, DO Mountlake Terrace WA

ACOFP 46th Annual Convention & Exhibition Gaylord National Resort & Convention CenterWashington, DC

March 4-8, 2009Renew and Discover!Keep your calendars open for March 4 - 8, 2009 to attend the American College of Osteopathic Family Physicians' 46th Annual Convention & Exhibition at the Gaylord National Resort & Convention Center, in Washington, DC Get ready to wield some political influence! Watch for program, social, travel, lodging and registration information in coming issues of Osteopathic Family Physician News and on the ACOFP's website at acofp.org

46th Annual ACOFP Convention & ExhibitionMarch 4 – 8, 2009Gaylord National Resort & Convention CenterWashington, DC

Save the Date ACOFP 2009

46TH ANNUA

L C

ON

VENTIO N & EXHIBITIO

N

W A S H I N G T O N D . C .



OFP News Offers 1-B CME

ACOFP members who read the Osteopathic FamilyPhysician News can receive two hours of Category 1-B continuing medical education credit for

completing quizzes in the journal and its supplements.Take the quizzes via www.acofp.org by first clicking

on ‘Education’ in the left-hand toolbar, then ‘CME Quizzes’.After page loads, click on to the link titled ‘April 2008 CMEQuiz’ that launches the .pdf file.

January/February CME Quiz Answers1. a; 2. b; 3. a; 4. d; 5. c; 6. b; 7. a; 8. d; 9. b; 10. a

CMEArticlecme

R E S O U R C E

A p r i l 2 0 0 8

April 24-27, 2008Oklahoma Osteopathic Association 108th Annual Convention “Osteopathic Medicine: Reaching New Heights”Cox Business Services Convention Center, Oklahoma City, OKContact [email protected]

April 25-26, 2008Minnesota Osteopathic Medical Society 110th Annual Convention and CMEThe Depot Convention Center, Riverfront Downtown Minneapolis, MNContact [email protected]

April 25 – 26, 2008Inaugural CME Program, “Diabetes and the Osteopathic Physician, Cradle to Grave Management ofDiabetes” Sponsored by the Idaho Osteopathic Physicians Association16 hours of Category 1-A CME anticipated, pending approval by AOA CCMEHampton Inn & Suites - Downtown, Boise, IDContact [email protected]

April 26-27, 2008North Carolina Society of the ACOFP 8th Annual Spring Conference16 1-A CME credits pending AOA approvalGrandover Resort & Spa, Greensboro, NCContact [email protected]

M a y 2 0 0 8

May 1-4, 2008Indiana Osteopathic Association 111th Annual ConventionSheraton Indianapolis Hotel & Suites, Keystone at the CrossingContact Mike Claphan 800-942-0501

May 1 – 4, 2008Virginia Osteopathic Medical Association Spring CME Conference24 1-A CME credits pending approval by the AOAThe Great Wolf Lodge, Williamsburg, VAVisit voma-net.org/conferences

May 16 – 18, 20082008 Annual Oceanside CME Sponsored by the Connecticut Osteopathic Medical Society24 hours of Category 1-A CME anticipated pending approval by the AOA CCME. Mystic Marriott Hotel & Spa, Groton, CTContact [email protected]

J u n e 2 0 0 8

June 13 – 15, 2008Maine Osteopathic Association2008 Annual Oceanside ConventionSamoset Resort, Rockport, MEContact: [email protected]

Calendar of Events

WWW.GEISINGER.ORG/DOCJOBS

Geisinger Health System, located in central and northeasternPennsylvania, is not only providing great Family Medicine for theirpatients but is a leader in defining national best practices.

Geisinger Health System has already implemented the newestAAFP recommendations and is helping to build a new model offamily practice that builds on the core values of Family Medicine –safe, timely, effective, efficient, equitable and patient centered.

• Received the 2007 American Medical Group Association’sPreeminence Award in recognition of its quality, leadership andservice.• Nationally recognized for excellence in diabetes care by theNational Committee for Quality Assurance and the AmericanDiabetes Association’s Diabetes Physician Recognition Program.

Geisinger currently has multiple Family Medicine opportunitiesavailable and is committed to providing our physicians with thesupport they need to enjoy a rewarding, successful career.

Generous medical student loan repayment and recruitmentincentives available.

We offer:• Small community (not isolated) practices that are supported bya comprehensive network of more than 40 community medicalgroups and an integrated network of over 650 Geisingerprimary and specialty physicians, all connected by EPIC EHR.• Comprehensive benefits package, including full medicalmalpractice insurance with tail coverage, 4 weeks of vacationand 3 weeks of CME annually (with stipend)• Lifelong learning tools to support a succession of career stages

At Geisinger, you can practice (and help define) leading-edgeFamily Medicine without the stress associated with big-city life.Here, you’ll enjoy an enviable work/life balance and experience allthe benefits of Pennsylvania living. Our region offers affordablehousing in safe neighborhoods with superior educationalopportunities from preschools to major universities; a dramaticlandscape that includes mountains, lakes and streams that areperfect for hiking, biking, skiing and fishing; and a vast array ofcultural and recreational activities for you and your family toenjoy. And it’s all just an afternoon’s drive from NewYork City,Philadelphia, Baltimore andWashington, DC.

For more information, contact:Lisa Brown, Professional RecruiterGeisinger Health System, 1000 E. Mountain Blvd.,Wilkes-Barre, PA 18711-3462Phone: 1.800.845.7112 • Fax: 1.800.622.2515Email: [email protected]

LIVE THE FUTURE OFFAMILY MEDICINE.

Information you need to make the right decision will be shared with you in this brief

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2008 Convention SchedulePlease visit our exhibit at these medical conventions

January16 - 19 PCOMS | St. Pete Beach, FL24 - 27 POMA | Farmington, PA

February7-10 TOMA | Dallas, TX15 -17 Pri-Med | Ft. Lauderdale, FL21- 24 FOMA | Ft. Lauderdale, FL

March6 - 8 Pri-Med | Houston, TX12 -16 ACOFP | Denver, CO

April4 - 5 WHF | Houston, TX8 - 10 AROC | Atlantic City, NJ15 - 16 AOMA | Scottsdale, AZ24 - 27 Pri-Med | Rosemount, IL

May3 - 6 AAPM | Honolulu, HI8 - 10 Pri-Med | Anaheim, CA14 - 18 AACE | Orlando, FL22 - 25 IFM | Carlsbad, CA30 - 31 WHF | Philadelphia, PA

June

17 - 20 TOMA | Dallas, TX19 - 22 OAO | Columbus, OH27 - 28 WHF | Chicago, IL27 - 7/1 APPNA | Washington, DC

July30 - 8/3 FLACOFP | Orlando, FL

August8 - 10 POMA | Hershey, PA

September12 - 14 FOMA | Tampa, FL

October3 - 5 Pri-Med | New York, NY11 - 13 AAPM | Boston26 - 30 AOA | Las Vegas, NV

November7 - 9 Pri-Med | Boston

December4 - 6 Pri-Med | Baltimore

Call us today to schedule your online meeting at: 1-888-778-7191

or email us at: [email protected]

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