Letters
RAND method,3 rather than relying on the consensus of a narrower specialty base as in the study by Kovacs et al.4 The scenarios developed for this process are both comprehensive and specific, making it very easy to link any given scenario with those rated by the expert panel. We performed an audit of this process to ensure that the linkage with predetermined scenarios was being performed in the same way at both sites. We did not encounter any cases that we could not specifically match with a previously rated scenario. For the 63.7% of lumbar spine requisitions where the requisition information was inadequate, we sought information from an electronic medical record or from the patient. We agree that this may affect the results, but, in fact, we were able to obtain the required information for all of the patients used in our analysis. Our study used the actual requisitions submitted to the 2 sites. None of the referring physicians was aware that the study was taking place, so their behavior should not have been affected. The fact that there was no significant difference in the results between the 2 sites studied suggests that the data are reasonably generalizable to our health system. We agree that the results will vary across different health systems. Our study differs significantly from the study by Kovacs et al,4 which relied on patient questionnaires regarding the presence or absence of “red flags.” The presence of a single “red flag” classified the study as appropriate. The sensitivity of guidelines based on “red flags” to potentially detect serious disease is high, but the specificity and positive predictive value are low. For instance, that study classified MRI requests as appropriate if the patients had the following “red flags”: age older than 70 years, minor trauma at age older than 50 years, and venous “puncture” in the preceding 6 months. Many experienced clinicians would not consider these as sufficient to call a lumbar MRI request appropriate. Thus, the study by Kovacs et al4 is biased toward classifying lumbar spine MRIs as appropriate, so it is not surprising that it found a lower incidence of inappropriate lumbar spine MRIs compared with our study. We agree that electronic clinical decision support might help reduce the proportion of inappropriate imaging studies. The empowerment of radiologists to decline inappropriate studies may also reduce inappropriateness, providing that there is widespread agreement on what is appropriate. Derek J. Emery, MD Thomas E. Feasby, MD, FRCPC Author Affiliations: Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada (Emery); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (Feasby); Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada (Feasby). Corresponding Author: Derek Emery, MD, Department of Radiology and Diagnostic Imaging, University of Alberta, 8440–112 St, Edmonton, AB T6G 2B7, Canada ([email protected]). Conflict of Interest Disclosures: None reported. 1. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013;173(9):823-825. 2. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63. jamainternalmedicine.com
3. Coulter I, Adams A, Shekelle P. Impact of varying panel membership on ratings of appropriateness in consensus panels: a comparison of a multi- and single disciplinary panel. Health Serv Res. 1995;30(4):577-591. 4. Kovacs FM, Arana E, Royuela A, et al. Appropriateness of lumbar spine magnetic resonance imaging in Spain. Eur J Radiol. 2013;82(6):1008-1014.
Topical Anesthetic-Induced Methemoglobinemia and Veterans Affairs Hospitals To the Editor Chowdhary and colleagues1 provide an excellent review of topical anesthetic–induced methemoglobinemia, reporting that benzocaine-containing topical anesthetics and inpatient status were the greatest risk factors for developing this rare but life-threatening complication. This review is particularly timely, as there continue to be flavored over-the-counter benzocaine products available. More recently a “unit-dose” benzocaine product was released, but it is unknown that this product will decrease methemoglobinemia.2 Given the strong association of methemoglobinemia and benzocaine 3 and the availability of other safer and effective agents to anesthetize the nasopharyngeal-oropharyngeal region for procedures, one should ask why clinicians continue to use benzocainecontaining products. The US Department of Veterans Affairs (VA) made the decision to remove all benzocaine-containing topical sprays used to anesthetize surfaces of the nasopharynx, oropharynx, and laryngotracheal regions and airways in February 2006.4 All benzocaine-containing throat lozenges were removed from the VA formulary in December 2008. Although this policy change was no doubt inconvenient to VA physicians performing certain procedures, those clinicians have been able to adapt to safer alternatives for topical anesthesia to the nasopharyngeal-oropharyngeal region. Chester B. Good, MD, MPH Muriel Burk, PharmD Francesca Cunningham, PharmD Author Affiliations: VA Center for Medication Safety, Hines, Illinois (Good, Burk, Cunningham); Center for Health Equities Research, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Good); Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Good). Corresponding Author: Chester B. Good, MD, MPH, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Building 30, University Drive, Pittsburgh, PA 15240-1001 ([email protected]). Conflict of Interest Disclosures: Drs Good, Burk, and Cunningham are employed by the Department of Veterans Affairs and the VA Center for Medication Safety. They have no other conflicts of interest to declare. 1. Chowdhary S, Bukoye B, Bhansali AM, et al. Risk of topical anestheticinduced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771-776. 2. Beutlich Pharmaceuticals, LLC, web site. www.beutlich.com. Accessed May 31, 2013. 3. Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med. 2004;164(11):1192-1196. 4. US Food and Drug Administration. Benzocaine sprays. www.fda.gov/Safety /MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts /ucm150501.htm. Accessed September 30, 2013.
In Reply We thank Good and colleagues for their insightful comments on our recently published article titled “Risk of Topical Anesthetic-Induced Methemoglobinemia.”1 We fully agree JAMA Internal Medicine November 25, 2013 Volume 173, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 05/28/2015
2013
Letters
with their uncertainty regarding significant advantages of the more recently released “unit-dose” benzocaine, given reports of adverse reactions even at minimal doses.2 Symptoms in patients receiving a minimal dose of benzocaine suggest significant variability in sensitivity to benzocaine dose. This greatly limits a clinician’s ability to devise a logical approach to administering safe amounts of topical benzocaine. This fact is undoubtedly one of the reasons that the Department of Veterans Affairs took the laudable, if difficult, action of removing benzocaine anesthetics from their system. Unfortunately, inertia in medical systems is significant, and from our own anecdotal experience, we would postulate that relatively straightforward interventions such as removing benzocaine products from hospital formularies have not been a focus because of competing pressures from various other internally and externally driven quality initiatives.3 On the basis of our findings and widespread reporting of lifethreatening complications with the use of benzocainecontaining agents, we agree with their assertion that clinicians should seriously consider using safer but equally effective alternatives, such as lidocaine. Indeed, this is a timely consideration in view of the growing accountability in health care and the unprecedented pressure to provide the safest and highest quality care to the rapidly expanding population undergoing invasive procedures.4
be a realistic solution to prevent people from PSA testing harms. Sadly, experience from France confirms his analysis. The guideline by the French National Cancer Institute (Institut National du Cancer [INCA]) flies in the face of evidence, advising “The decision to screen for this cancer (prostate) is taken on a case by case basis after discussion with his physician or urologist” (www.e-cancer.fr/cancerinfo/les-cancers /cancers-de-la-prostate/le-depistage). So does the French National Authority for Health (Haute Autorité de Santé, in charge of the quality of patient care), which states “Screening for prostate cancer should be a dialogue between a man and his doctor.”2 Accordingly, despite early warnings, PSA testing remains an epidemic in France, even in the eldest men.3 In 2010, among men 75 years or older, excluding those with known prostate cancer, 1 48% had at least 1 PSA test and 21% had more than 3 PSA tests between 2008 and 2010.4 The epidemic will not stop, as both the INCA and the Haute Autorité de Santé have not updated their leaflet informing lay people on the recent data from controlled trials on the risks and benefits of prostate cancer screening—the one presently available was issued in 2004.5
Bolanle Bukoye, MPH Daniel Leffler, MD, MS
Author Affiliation: Public Health, Northern Hospital, Amiens, France.
Author Affiliations: Boston Children’s Hospital, Boston, Massachusetts (Bukoye); Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Leffler).
Conflict of Interest Disclosures: None reported.
Corresponding Author: Daniel Leffler, MD, MS, Department of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Dana 501, Boston, MA 02215 ([email protected]).
2. Haute Autorité de Santé. Dépistage du cancer de la prostate chez les populations d’hommes présentant des facteurs de risque. www.has-sante.fr /portail/upload/docs/application/pdf/2012-04/questions_reponses_depistage _du_cancer_de_la_prostate_vdef.pdf. Accessed 25 April 2013.
Corresponding Author: Alain Braillon, MD, PhD, Public Health, Northern Hospital, 27 rue Voiture, 80000 Amiens, France ([email protected]).
Conflict of Interest Disclosures: None reported. 1. Chowdhary S, Bukoye B, Bhansali AM, et al. Risk of topical anestheticinduced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771-776. 2. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845. 3. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876-884. 4. Pfuntner A, Wier LM, Stocks C. Most Frequent Procedures Performed in US Hospitals, 2010: Statistical Brief #149. February 2013. www.hcup-us.ahrq.gov /reports/statbriefs/sb149.pdf. Accessed September 25, 2013.
Prostate-Specific Antigen Testing in France To the Editor Katz1 brilliantly showed why a rigorous informed consent about prostate-specific antigen (PSA) testing cannot
2014
Alain Braillon, MD, PhD
1. Katz MH. Can we stop ordering prostate-specific antigen screening tests? JAMA Intern Med. 2013;173(10):847-848.
3. Braillon A. Prostate specific antigen: prostate screening in France [letter]. BMJ. 2009;339:b4285. 4. Tuppin P, Samson S, Perrin P, et al. Prostate-specific antigen use among men without prostate cancer in France (2008-2010) [in French]. Bull Cancer. 2012;99(5):521-527. 5. Braillon A, Hill C, Dubois G. Prostate Specific Antigen (PSA), yet how much damage? [in French]. Presse Med. 2012;41(5):482-485.
CORRECTION Incorrect Name of Study Group: In the Research Letter titled “Ineffectiveness of Pneumococcal Vaccination in Cardiovascular Prevention: The CAPAMIS Study” published online May 27, 2013, in JAMA Internal Medicine (doi:10.1001 /jamainternmed.2013.6901), the name of the study group in the byline and list of study group members was incorrect and should have read “EPIVAC Study Group.” This article was corrected online.
JAMA Internal Medicine November 25, 2013 Volume 173, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 05/28/2015
jamainternalmedicine.com
RAND method,3 rather than relying on the consensus of a narrower specialty base as in the study by Kovacs et al.4 The scenarios developed for this process are both comprehensive and specific, making it very easy to link any given scenario with those rated by the expert panel. We performed an audit of this process to ensure that the linkage with predetermined scenarios was being performed in the same way at both sites. We did not encounter any cases that we could not specifically match with a previously rated scenario. For the 63.7% of lumbar spine requisitions where the requisition information was inadequate, we sought information from an electronic medical record or from the patient. We agree that this may affect the results, but, in fact, we were able to obtain the required information for all of the patients used in our analysis. Our study used the actual requisitions submitted to the 2 sites. None of the referring physicians was aware that the study was taking place, so their behavior should not have been affected. The fact that there was no significant difference in the results between the 2 sites studied suggests that the data are reasonably generalizable to our health system. We agree that the results will vary across different health systems. Our study differs significantly from the study by Kovacs et al,4 which relied on patient questionnaires regarding the presence or absence of “red flags.” The presence of a single “red flag” classified the study as appropriate. The sensitivity of guidelines based on “red flags” to potentially detect serious disease is high, but the specificity and positive predictive value are low. For instance, that study classified MRI requests as appropriate if the patients had the following “red flags”: age older than 70 years, minor trauma at age older than 50 years, and venous “puncture” in the preceding 6 months. Many experienced clinicians would not consider these as sufficient to call a lumbar MRI request appropriate. Thus, the study by Kovacs et al4 is biased toward classifying lumbar spine MRIs as appropriate, so it is not surprising that it found a lower incidence of inappropriate lumbar spine MRIs compared with our study. We agree that electronic clinical decision support might help reduce the proportion of inappropriate imaging studies. The empowerment of radiologists to decline inappropriate studies may also reduce inappropriateness, providing that there is widespread agreement on what is appropriate. Derek J. Emery, MD Thomas E. Feasby, MD, FRCPC Author Affiliations: Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada (Emery); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (Feasby); Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada (Feasby). Corresponding Author: Derek Emery, MD, Department of Radiology and Diagnostic Imaging, University of Alberta, 8440–112 St, Edmonton, AB T6G 2B7, Canada ([email protected]). Conflict of Interest Disclosures: None reported. 1. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013;173(9):823-825. 2. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63. jamainternalmedicine.com
3. Coulter I, Adams A, Shekelle P. Impact of varying panel membership on ratings of appropriateness in consensus panels: a comparison of a multi- and single disciplinary panel. Health Serv Res. 1995;30(4):577-591. 4. Kovacs FM, Arana E, Royuela A, et al. Appropriateness of lumbar spine magnetic resonance imaging in Spain. Eur J Radiol. 2013;82(6):1008-1014.
Topical Anesthetic-Induced Methemoglobinemia and Veterans Affairs Hospitals To the Editor Chowdhary and colleagues1 provide an excellent review of topical anesthetic–induced methemoglobinemia, reporting that benzocaine-containing topical anesthetics and inpatient status were the greatest risk factors for developing this rare but life-threatening complication. This review is particularly timely, as there continue to be flavored over-the-counter benzocaine products available. More recently a “unit-dose” benzocaine product was released, but it is unknown that this product will decrease methemoglobinemia.2 Given the strong association of methemoglobinemia and benzocaine 3 and the availability of other safer and effective agents to anesthetize the nasopharyngeal-oropharyngeal region for procedures, one should ask why clinicians continue to use benzocainecontaining products. The US Department of Veterans Affairs (VA) made the decision to remove all benzocaine-containing topical sprays used to anesthetize surfaces of the nasopharynx, oropharynx, and laryngotracheal regions and airways in February 2006.4 All benzocaine-containing throat lozenges were removed from the VA formulary in December 2008. Although this policy change was no doubt inconvenient to VA physicians performing certain procedures, those clinicians have been able to adapt to safer alternatives for topical anesthesia to the nasopharyngeal-oropharyngeal region. Chester B. Good, MD, MPH Muriel Burk, PharmD Francesca Cunningham, PharmD Author Affiliations: VA Center for Medication Safety, Hines, Illinois (Good, Burk, Cunningham); Center for Health Equities Research, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Good); Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Good). Corresponding Author: Chester B. Good, MD, MPH, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Building 30, University Drive, Pittsburgh, PA 15240-1001 ([email protected]). Conflict of Interest Disclosures: Drs Good, Burk, and Cunningham are employed by the Department of Veterans Affairs and the VA Center for Medication Safety. They have no other conflicts of interest to declare. 1. Chowdhary S, Bukoye B, Bhansali AM, et al. Risk of topical anestheticinduced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771-776. 2. Beutlich Pharmaceuticals, LLC, web site. www.beutlich.com. Accessed May 31, 2013. 3. Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med. 2004;164(11):1192-1196. 4. US Food and Drug Administration. Benzocaine sprays. www.fda.gov/Safety /MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts /ucm150501.htm. Accessed September 30, 2013.
In Reply We thank Good and colleagues for their insightful comments on our recently published article titled “Risk of Topical Anesthetic-Induced Methemoglobinemia.”1 We fully agree JAMA Internal Medicine November 25, 2013 Volume 173, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 05/28/2015
2013
Letters
with their uncertainty regarding significant advantages of the more recently released “unit-dose” benzocaine, given reports of adverse reactions even at minimal doses.2 Symptoms in patients receiving a minimal dose of benzocaine suggest significant variability in sensitivity to benzocaine dose. This greatly limits a clinician’s ability to devise a logical approach to administering safe amounts of topical benzocaine. This fact is undoubtedly one of the reasons that the Department of Veterans Affairs took the laudable, if difficult, action of removing benzocaine anesthetics from their system. Unfortunately, inertia in medical systems is significant, and from our own anecdotal experience, we would postulate that relatively straightforward interventions such as removing benzocaine products from hospital formularies have not been a focus because of competing pressures from various other internally and externally driven quality initiatives.3 On the basis of our findings and widespread reporting of lifethreatening complications with the use of benzocainecontaining agents, we agree with their assertion that clinicians should seriously consider using safer but equally effective alternatives, such as lidocaine. Indeed, this is a timely consideration in view of the growing accountability in health care and the unprecedented pressure to provide the safest and highest quality care to the rapidly expanding population undergoing invasive procedures.4
be a realistic solution to prevent people from PSA testing harms. Sadly, experience from France confirms his analysis. The guideline by the French National Cancer Institute (Institut National du Cancer [INCA]) flies in the face of evidence, advising “The decision to screen for this cancer (prostate) is taken on a case by case basis after discussion with his physician or urologist” (www.e-cancer.fr/cancerinfo/les-cancers /cancers-de-la-prostate/le-depistage). So does the French National Authority for Health (Haute Autorité de Santé, in charge of the quality of patient care), which states “Screening for prostate cancer should be a dialogue between a man and his doctor.”2 Accordingly, despite early warnings, PSA testing remains an epidemic in France, even in the eldest men.3 In 2010, among men 75 years or older, excluding those with known prostate cancer, 1 48% had at least 1 PSA test and 21% had more than 3 PSA tests between 2008 and 2010.4 The epidemic will not stop, as both the INCA and the Haute Autorité de Santé have not updated their leaflet informing lay people on the recent data from controlled trials on the risks and benefits of prostate cancer screening—the one presently available was issued in 2004.5
Bolanle Bukoye, MPH Daniel Leffler, MD, MS
Author Affiliation: Public Health, Northern Hospital, Amiens, France.
Author Affiliations: Boston Children’s Hospital, Boston, Massachusetts (Bukoye); Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Leffler).
Conflict of Interest Disclosures: None reported.
Corresponding Author: Daniel Leffler, MD, MS, Department of Gastroenterology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Dana 501, Boston, MA 02215 ([email protected]).
2. Haute Autorité de Santé. Dépistage du cancer de la prostate chez les populations d’hommes présentant des facteurs de risque. www.has-sante.fr /portail/upload/docs/application/pdf/2012-04/questions_reponses_depistage _du_cancer_de_la_prostate_vdef.pdf. Accessed 25 April 2013.
Corresponding Author: Alain Braillon, MD, PhD, Public Health, Northern Hospital, 27 rue Voiture, 80000 Amiens, France ([email protected]).
Conflict of Interest Disclosures: None reported. 1. Chowdhary S, Bukoye B, Bhansali AM, et al. Risk of topical anestheticinduced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771-776. 2. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845. 3. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876-884. 4. Pfuntner A, Wier LM, Stocks C. Most Frequent Procedures Performed in US Hospitals, 2010: Statistical Brief #149. February 2013. www.hcup-us.ahrq.gov /reports/statbriefs/sb149.pdf. Accessed September 25, 2013.
Prostate-Specific Antigen Testing in France To the Editor Katz1 brilliantly showed why a rigorous informed consent about prostate-specific antigen (PSA) testing cannot
2014
Alain Braillon, MD, PhD
1. Katz MH. Can we stop ordering prostate-specific antigen screening tests? JAMA Intern Med. 2013;173(10):847-848.
3. Braillon A. Prostate specific antigen: prostate screening in France [letter]. BMJ. 2009;339:b4285. 4. Tuppin P, Samson S, Perrin P, et al. Prostate-specific antigen use among men without prostate cancer in France (2008-2010) [in French]. Bull Cancer. 2012;99(5):521-527. 5. Braillon A, Hill C, Dubois G. Prostate Specific Antigen (PSA), yet how much damage? [in French]. Presse Med. 2012;41(5):482-485.
CORRECTION Incorrect Name of Study Group: In the Research Letter titled “Ineffectiveness of Pneumococcal Vaccination in Cardiovascular Prevention: The CAPAMIS Study” published online May 27, 2013, in JAMA Internal Medicine (doi:10.1001 /jamainternmed.2013.6901), the name of the study group in the byline and list of study group members was incorrect and should have read “EPIVAC Study Group.” This article was corrected online.
JAMA Internal Medicine November 25, 2013 Volume 173, Number 21
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Iowa User on 05/28/2015
jamainternalmedicine.com
