11/20/12 Annals

The 11/20/12 Annals is not one of their better issues, IMHO. There are a bunch of articles that aren't all that interesting to me and then there are two sets of recommendations, one for the diagnosis of stable ischemic heart disease and one for its management. They're kind of long and detailed, but include nice algorithm charts. The big surprise for me was all the emphasis they put on exercise EKG as the initial test for people of intermediate probability. I was taught that an exercise EKG is not very sensitive or specific and in my career, I may have ordered two. The editorialist talks about this being a big surprise for him as well (also there is what I can only assume is a typo in the editorial: he says "women" but the recommendations clearly say "patient"). Otherwise, the emphasis on medical management is, if anything, even stronger than it has been in recent recommendations which is nice to see for a general internist.

Additionally, there was an article about pharmacy dispensation of discontinued meds. When I stop a med in the office, the EMR does not inform the pharmacy that I want the patient to stop this med and sometimes the pharmacist can reasonably be expected to figure out to stop it (I send an rx for a higher dose of the same med or I send an rx for a different med of the same class), but sometimes there is no way they could possibly know and we all have to rely on the patient refusing the med when it gets filled for them. This is not a very robust system, clearly with patients of marginal literacy of all kinds as well as just generally overwhelmed or confused and on ten different meds. Anyway, these researchers were able to track down for about half the prescriptions they were interested in whether or not they were dispensed after a discontinuation order was put in the EMR and about 1.5% of the meds were dispensed an average of once over the next twelve months. Wow! It's both surprising that the number is so low (the pharmacists are doing such a good job of reading the doctors minds or calling for clarification) and surprising that the number is so high as these are potentially serious errors with dangerous meds (antiplatelet, antihypertensives, hypoglycemics). I try to include notes to the pharmacist about meds I'm discontinuing, but I don't do it reliably. Yikes! I just never thought about this as an Achilles heel of prescribing.