Challenge of
electronic medical records
T
he June issue has a thoughtful arti- cle1by Dr Newbery on continuity:the continuity of relationships and of approaches to treatment and abilities.
He describes the computer as being unable to ensure continuity, yet it is the computer that will allow the most impor tant continuity in family medi- cine: that of patient care.
The thread of continuity is more impor- tant today than in the past. The appear- ance of breast screening clinics and cervical testing clinics attests to deficien- cies in our recall programs. The care these clinics provide is discontinuous because they care for only one aspect of health. On the other hand, they follow a disease- specific preventive program over time.
With recent advances in postinfarct care or diabetic management, for exam- ple, disease-specific continuity of care becomes more critical. Many diseases require years of ongoing management.
Many patients have multiple health problems and take multiple treatments that are difficult to follow. It is also diffi- cult to remember when to initiate pre- ventive maneuvers, such as ophthalmic assessment for diabetics or immuniza- tion updates. The thread of continuity needs to weave through all these areas.
Family doctors are the only health care professionals who have the breadth of practice to coordinate care for patients. Continuity of care should imply continuity over a disease process, not just episodic care when patients present with a problem.
Flow charts are cumbersome to use for remembering, for example, when
menopause star ted, whether a hys- terectomy has been done, what the results of the last Pap smear were and whether another one needs to be done this year, when the last breast exami- nation was performed or mammogram or bone density test was done, whether hormone replacement thera- py has been discussed, and whether breast cancer has affected the family.
Many other patterns of care require similar diligent documenting of previ- ous events to help direct current care.
How many other maneuvers are not used because we are not organized to think of our patients over time?
Dr Newbery is right on two counts. It is time to rethink continuity, and current
computer programs are not up to the job of giving us this type of information about our patients. As family doctors we need to take on the challenge of elec- tronic medical records. Computerized electronic records make patient data easily accessible and can display infor- mation in a useful manner. Char ts become useful documents rather than files of paper sitting in a cabinet.
Triggers for timely use of preventive maneuvers can be built into the pro- gram. We must think about what data will help us manage our patients and how the data we have can be most use- ful to us, how we can best follow the threads of our patients’ health.
Continuity of care across patients’
health spectrum can be a reality with computerized records. With the com- plexity of maneuvers with which we have to deal, this is the future of family medicine.
— J. Graham Swanson, MD, MSC, CCFP, FCFP
Burlington, Ont
Reference
1. Newbery P. Time to rethink continuity. Can Fam Physician2000;46:1248-9 (Eng), 1256-7 (Fr).
Olanzapine: keep an eye on this neuroleptic
A
s a French-speaking physician, I found some errors in the transla- tion of the original Prescrire article,1“Olanzapine. Keep an eye on this neuroleptic.”
The article gave a bad impression of “novel” or “atypical” antipsychotics in general and of olanzapine in partic- ular, which is absolutely unjustified based on a large scientific database
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and on an international consensus of physicians (family physicians, psychi- atrists, experts) who prescribe these drugs.
The unknown French authors of this review did not seem to have strong (or any?) clinical experience with olan- zapine (not marketed in France at the time of publication). They made false interpretations of or statements about the published data on olanzapine and other novel antipsychotics. For exam- ple, their definition of atypical neu- roleptics is incor rect based on international literature.2 The compara- tive trial by Tran et al3 demonstrates some superiority of olanzapine over risperidone. One of the most intriguing and important findings of that study was a significantly lower relapse rate
for olanzapine at 28 weeks of follow up compared with risperidone.
It is unclear whether any of these agents produce a greater effect than conventional neuroleptics against posi- tive symptoms. Clozapine shows the most convincing efficacy (not yet sur- passed) in well-defined refractory schiz- ophrenia. Both clozapine and olanzapine have demonstrated superior efficacy against negative symptoms, but it is unclear whether this is an effect on pri- mary or secondary negative symptoms (related to extrapyramidal symptoms).
Path analysis does suggest that olanzap- ine has a primar y effect on negative symptoms and mood symptoms.4
Most of these agents have demon- strated superior efficacy against conven- tional agents on other symptoms of schizophrenia (affective and cognitive) in many double-blind trials; the degree to which the new compounds are clini- cally superior will require further study.
Second-generation compounds are also not all alike; lack of response to one does not preclude response to another.
All the newer agents used in Canada, clozapine; risperidone; olanza- pine; quetiapine; and, coming soon, ziprasidone (amisulpiride is not avail- able here), are clearly superior for extrapyramidal symptoms and, with the exception of risperidone, avoid sub- stantial elevation of prolactin levels.5 One of the most important aspects of novel antipsychotics is their increased tolerability (especially decreased extrapyramidal symptoms and a probable diminished risk for irre- versible tardive dyskinesia). Patients who have fewer side effects are more likely to comply with their medication (noncompliance is an important issue in the treatment, prevention of relapse, and overall cost of schizophrenia).6 The warning about active sur veil- lance of patients receiving olanzapine because of putative major side effects is completely incorrect and misleading (the drug could cause transient and mild elevation of hepatic transaminase with
no case repor t of hepatitis or any induced liver disease; very small Q-T prolongation, also seen with other atypi- cal and even more so with typical neu- roleptics, with no clinical significance;
small and nonsignificant increased blood pressure, yet in clinical practice we see more of a nonsignificant decrease, etc).
My own rating of this misleading article is “not acceptable.” The most damage from this kind of supposed “evi- dence-based” drug review could be to our psychotic patients who are in great need of the best treatment available.
These “second generation, novel, or atypical” antipsychotics improve the benefit-risk ratio because they have equal or better effect on many symp- toms of schizophrenia, a better or a much better tolerability, and a greater likelihood of improving compliance and quality of life for our patients with schizophrenia and related disorders.
These medications are now our first- line treatment option.
—Gérard Leblanc, MD, FRCP, PSYCHIATRIST
Québec City, Que
References
1. Prescrire. Evidence-based drug reviews.
Olanzapine. Keep an eye on this neuroleptic.
[Prescrire]. Can Fam Physician 2000;46:321- 6 (Eng), 330-6 (Fr).
2. Stahl SM. Selecting an atypical antipsychot- ic by combining clinical experience with guidelines from clinical trials. J Clin Psychiatry1999;60:31-41.
3. Tran PV, Hamilton SH, Kuntz AJ, Potvin JH, Andersen SW, Beasley C Jr, et al. Double- blind comparison of olanzapine versus risperidone in the treatment of schizophre- nia and other psychotic disorders. J Clin Psychopharmacol1997;17:407-18.
4. Tollefson GD, Sanger TM. Negative symp- toms: a path analytic approach to a double- blind, placebo and haloperidol-controlled clinical trial with olanzapine. Am J Psychiatry 1997;154:466-74.
5. Working Group for the Canadian Psychiatric Association and the Canadian Alliance for Research on Schizophrenia.
Canadian clinical practice guidelines for the
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Letters
❖Correspondance
treatment of schizophrenia. Can J Psychiatry 1998;43(Suppl 2):21S-41S.
6. Work Group on Schizophrenia. Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry 1997;154 (4 Suppl):1-63.
Response
La revue Prescrire’s editorial staf f, whose members are unknown only to those who do not take the trouble to read the list in each issue, have long been persuaded that it is in patients’
best interests for drugs to be strictly assessed and for health professionals to be objectively informed.
A practitioner’s own clinical experi- ence on the efficacy of a given treat- ment, including neuroleptics, carries a very low level of evidence. For exam- ple, many physicians for years pre- scribed diethylstilbestrol (DES) in early pregnancy, on the basis of their person- al experience, despite the unconvincing results of well-conducted trials and with the tragic consequences we all know.
The editorial procedures used by la revue Prescrireare mentioned in each issue of Canadian Family Physician, and a detailed version1 was published in May 1999. Our articles are not “sup- posed evidence-based.” All our state- ments are precisely referenced, and all references (complete) are filed and available upon request, allowing readers to check the accuracy of each article.
Regarding olanzapine, the initial clinical assessment file failed to demonstrate that it was more effective than the neuroleptics with which it had been compared. (As for the trial by Tran et al, we stressed the fact that the larger the number of statistical com- parisons, the greater the likelihood of finding a “significant” difference pure- ly by chance.)
Based on a sound search for clini- cal trials comparing olanzapine with placebo or any antipsychotic treat- ment for those with schizophrenia or
schizophrenifor m psychoses, the authors of a recent Cochrane system- atic review have concluded:
The very great losses of follow up make rec- ommendations difficult. In these trials most people given olanzapine stop it within six months to one year. Global impression sug- gests that 10-15 mg/day of olanzapine is antipsychotic, being better than placebo, but, for those with severe illness, when compared to typicals and atypicals there is little differ- ence for the same outcome. On one sub-scale score, of one mental state rating scale, olan- zapine shows superiority over antipsychotics for negative symptoms. This results is diffi- cult to interpret clinically. Such findings need replication in large simple studies and should not form the evidence base of treat- ment recommendations. Olanzapine may have fewer extrapyramidal effects than chlor- promazine and haloperidol, and, perhaps, than risperidone.… Currently not enough data relating to those with treatment-resis- tant schizophrenia are available to draw definitive conclusions.2
Finally, warning readers of the lack of long-term safety follow up and call- ing for caution, as with all new drugs, is not in our view “completely incor- rect.” On the contrary, it is absolutely crucial. Physicians must remain alert to avoid repeating er rors such as those committed with DES, isoxicam, terfenadine, vigabatrin, cisapride, and mibefradil, to name a few, all of which were initially heralded as being “more effective and safer.”
—Dr Bruno Toussaint Chief Editor, la revue Prescrire
References
1. Reid T. Welcome to Prescrire! Evidence- based reviews of drugs [editorial]. Can Fam Physician1999;45:1133-4 (Eng), 1140-1 (Fr).
2. Duggan L, Fenton M, Dardennes RM, El- Dosoky A, Indran S. Olanzapine for schizo- phrenia. The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration. Oxford, Engl: Update soft- ware; 2000. Issue 2.
Corrections
I
n the article by Reid et al, “Family physicians and maternity care. Still in the game?” (Can Fam Physician 2000;46:601-11), an error appeared in the opening sentence of the second paragraph of the introduction on page 602. The sentence should read, “In 1983, 36% of family doctors attended bir ths, but by 1995 this figure had dropped to 32%.9” The authors apolo- gize for this error.* * *
In the Motherisk Update column in the April issue, “Caffeine during pregnan- cy?” (Can Fam Physician 2000;46:801-3), a meta-analysis completed by the Motherisk program suggested that the risk for miscarriage and fetal growth retardation increased with daily doses of caffeine above 150 mg/d.1This dose was incorrectly reported in the update to be equivalent to six typical cups of coffee a day. Although caffeine content varies among different coffee brands, in the original meta-analysis a cup of cof- fee was approximately 100 mg in most of the studies included or defined as 74 mg if not reported in the original paper.
To calculate daily caffeine doses from beverages, the following mean caffeine equivalents can be used as guidelines2:
• cof fee: 100 mg per 250-mL cup,
• decaf feinated cof fee: 2 mg per 250-mL cup,
• tea: 40 mg per 250-mL cup, and
• cola: 47 mg per 375-mL can.
References
1. Fernandes O, Shabarwal M, Smiley T, Pastuszzak A, Koren G, Einarson T.
Moderate to heavy caffeine consumption and relationship to spontaneous abortion and abnormal fetal growth: a meta-analysis.
Reprod Toxicol1998;12:435-44.
2. Bunker ML, McWilliams M. Caffeine con- tent of common beverages. J Am Diet Assoc 1979;74:28-32.
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