BETHESDA, Md. — CodeRyte(TM), Inc. announced today that Abercrombie Radiology, an 80-year-old radiology group in Knoxville, Tenn., and Healthcare Administrative Partners, a medical billing and practice management company in Media, Pa., will both begin using CodeRyte’s automated diagnostic and interventional radiology (IR) technology to streamline and improve their radiology coding and billing operations.

“We look forward to implementing CodeRyte’s technology to enhance our coding and practice management solutions,” said Brian Effron, president and chief executive officer of Healthcare Administrative Partners. “We feel confident that CodeRyte is equally committed to improving healthcare efficiency and quality by streamlining the medical coding process.”

CodeRyte recently introduced its IR coding tool that automates coding for angiography, the most complicated subset of radiology coding. The angiography application features anatomy diagrams for each note, an important resource for coding angiograms. The combination of automated coding, coding-to-billing workflow and graphic enhancements brings simplification and process management to the intricate field of angiography coding.

“We heard from several other radiology groups that CodeRyte is a very good company and that its services are very helpful to their practices,” said Shannon Hampson, administrator of Abercrombie Radiology.

SAN DIEGO, Calif. — Artificial Medical Intelligence (AMI) today announced that Robert Wood Johnson University Hospital (RWJUH) New Brunswick, New Jersey, has deployed its EMscribe Dx computer assisted coding solution to improve the hospital’s medical records processing.

EMscribe Dx is a computer assisted coding solution that extracts medical phrases from free text documents and matches them to appropriate ICD9 diagnostic and procedure codes. It is the only automated coding solution specifically designed for hospital coding requirements and covers all clinical disciplines and subspecialties.

“We selected AMI’s EMscribe Dx as part of an effort to streamline our medical records processing and code more efficiently while supporting our goal of applying new technologies to improve healthcare,” said John Gantner, executive vice president and CFO at RWJUH. “AMI has demonstrated its ability to address our long-term objectives, streamline our data collection and provide us with earlier visibility into a patient’s chart for better decision making. We intend to integrate EMscribe Dx with our existing hospital systems as part of a new data acquisition and management environment.”

RWJUH previously depended on a primarily manual coding process that was tedious and time consuming. After a patient was discharged, a clerk would physically retrieve the medical documents and pass it to a health records analyst who would extract the appropriate information for the billing system. Then the medical record would be passed onto a coder who would write the codes onto a paper face sheet. Next the face sheet would get passed to a data entry operator who would again access the billing system and enter the coding information into the account for final billing.

Hysterectomy is a common surgical procedure that provides definitive treatment for menorrhagia. However, many women prefer to continue medical therapy for several years because hysterectomy is irreversible and associated with surgical risks. No randomized controlled trials have compared medical and surgical treatment of menorrhagia in women who did not have a strong preference or medical indications for either strategy. Learman and colleagues compared the outcome of these two treatment strategies in 63 premenopausal women referred to four teaching hospitals in the United States because of symptomatic menorrhagia.

Study participants were 30 to 50 years of age and reported abnormal menstrual flow lasting more than seven days each month or sufficient flow to cause anemia for at least two months. Women who were older than 45 years were tested for menopause by measuring follicle-stimulating hormone level and also were tested for endometrial hyperplasia or carcinoma before being enrolled in the study. Exclusion criteria included coagulopathies, other causes of anemia, endocrine conditions, pelvic pathology, desire for pregnancy, and recent use of oral contraceptives or long-acting hormonal therapies.

A total of 413 women initially began the trial and were given cyclic medroxyprogesterone acetate for 10 to 14 days per month. Patients who were dissatisfied with this regimen were invited to participate in the comparison trial of hysterectomy and extended medical therapy. Patients assigned to medical therapy received a combined oral contraceptive plus a prostaglandin inhibitor, but variations in the actual regimen were permitted. Patients were followed every three months for two years to assess health status, beliefs and attitudes, gynecologic and urinary symptoms, and other relevant symptoms, such as back pain and sexual function.

On entry to the study, both groups reported multiple pelvic symptoms and low satisfaction with their current health status and symptom management. The median duration of abnormal bleeding symptoms was three to four years. Initially, 29 of the 32 women assigned to medical treatment received hormonal therapy, but only 17 of these women also received a prostaglandin inhibitor. Within two years, 17 of these women had undergone a hysterectomy.

Of the 31 women assigned to hysterectomy, 28 had the surgery. Most of these women (86 percent) required a one- to two-day hospitalization. Two patients had perioperative complications and three required readmission because of late complications. After six months, women in the hysterectomy group reported significantly greater improvements in pelvic pain, breast pain, urinary urgency, and sensation of incomplete bladder emptying than women receiving medical treatment. They also reported nonstatistically significant improvements in pelvic or bladder pressure and lower back pain compared with women treated medically.

By two years, the most significant differences recorded between the groups were hot flushes and incomplete bladder emptying. Women who remained on medical treatment showed significant improvements from baseline in pelvic pain, pelvic or bladder pressure, and stress incontinence symptoms. Women who crossed over to hysterectomy reported significant improvements in bleeding; pelvic, back, or breast pain; and urinary frequency and urgency. Conversely, women who crossed over from medicine to hysterectomy had more days lost from usual activities and more days in bed than women who remained on medical therapy.

The authors conclude that hysterectomy may be the better treatment option for women who seek relief of symptoms such as bleeding, pelvic pain, breast pain, lower back pain, and bladder symptoms. Conversely, medical therapy can provide substantial improvements in symptoms with fewer overall days of restricted activities in the short term for women who do not want to have a hysterectomy.

ANNE D. WALLING, M.D.

Learman LA, et al. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical outcomes in the medicine or surgery trial. Obstet Gynecol May 2004;103:824-33.

EDITOR’S NOTE: Deciding on the optimal treatment strategy for an individual woman with menorrhagia can be challenging for several reasons. Although the medical literature is difficult to assess objectively, about one third of patients are reported to have strong personal preferences for a specific therapy. The options are much wider than suggested in this article. A review (1) in the BMJ Best Treatments series (http://www.besttreatments.org) concluded that nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, hysterectomy (after failure of medical therapy), and endometrial thinning before hysteroscopic surgery are “treatments that work,” and that endometrial destruction (after failure of medical therapy) is a “treatment likely to work.”

“Treatments that need further study” include ethamsylate, oral contraceptives, intrauterine progesterones, gonadotropin-releasing hormone (GnRH), and myomectomy. One of the more interesting facts found in this review is that women adequately treated with NSAIDs reported a 25 to 50 per-cent reduction in bleeding, but in the above study, only a small proportion of the women assigned to treatments including NSAIDs actually took them. Although hysterectomy is the definitive therapy for menorrhagia (and the leading indication for the more than 600,000 hysterectomies performed in the United States per year), studies that followed patients for more than two years after hysterectomy or endometrial ablation found no significant difference between the groups in satisfaction at longer follow-up. Women treated by endometrial ablation were calculated to have a mean reduction in operating time of 23 minutes and returned to work 4.5 weeks sooner than women undergoing hysterectomy.–A.D.W.

Several abbreviated checklists perform well in distinguishing children with attention deficit/ hyperactivity disorder (ADHD) from those without ADHD under ideal conditions and in research settings. While many guidelines and experts recommend using these checklists as an efficient method to collect data from multiple sources (strength of recommendation: B, based on extrapolation from cohort studies to define test characteristics and consensus opinion), experts point out the subjective nature of responses on behavior rating scales, and the limitations in using checklists as the sole source of information.

The Swanson, Nolan, and Pelham (SNAP) checklist from the Diagnostic and Statistical Manual of Mental Disorders, revised 3rd edition (DSM-III-R) has been shown to have a sensitivity and specificity in excess of 94% to distinguish hyperactive, inattentive, and impulsive children with ADHD from those without ADHD. This was based on criteria in the DSM-III-R. The DSM-IV SNAP checklist (available at www.adhd.net/snap-iv-form.pdf; scoring at www.adhd.net/snap-iv-instructions.pdf), based on the newer diagnostic criteria, has not been adequately evaluated. The ADHD Rating Scale-IV (in DuPaul et al, AD/-/D Rating Scale IV–Checklists, Norms, and Clinical Interpretations, available from Guilford Press) and the ADD-H Comprehensive Teacher/Parent Rating Scale (ACTeRS; available from MetriTech, Inc at www.metritech.com) are useful for their brevity, but they do not perform as well in differentiating children with ADHD from those without ADHD.

* EVIDENCE SUMMARY

A variety of brief ADHD-specific rating scales are used for both parent and teacher assessment of child behavior. Rating scales are generally evaluated to establish mean scores for affected and unaffected children. Many scales publish such normative data in commercially available manuals. Some scales have been evaluated by 1 or more independent studies to compare children with and without ADHD. Rating scales have not been evaluated as a sole tool for the diagnosis of ADHD.

The test characteristics of a particular scale depend on the cut points for a positive or negative test. The usefulness of psychological tests in discriminating normal from abnormal behavior is often reported as “effect size.” The effect size is the difference in mean scores between 2 populations divided by an estimate of the individual standard deviation. (1) An effect size of 4.0 means that abnormal subjects and normal controls are separated 4 standard deviations and thus almost completely separated. An effect size of 1.0 shows significant overlap between the 2 populations. An effect size of 4.0 is roughly equivalent to a sensitivity and specificity of 97%. An effect size of 1.0 is roughly equal to a sensitivity and specificity of 71%.

Table 1 outlines the characteristics and effect size of several available brief ADHD-specific checklists. (2-4,6,11-13) Typically, the gold standard was a clinical diagnostic interview, usually conducted by a clinical psychologist, as well as supporting data from schools and parents.

* RECOMMENDATIONS FROM OTHERS

The American Academy of Pediatrics states that the use of ADHD-specific checklists is a clinical option when evaluating children for ADHD. They caution that the ADHD scales may function less well in clinicians’ offices than suggested by reported effect size and, in addition, rating scales are subject to bias and may convey a false sense of validity. They also state that it is not known if these scales provide additional information beyond a careful clinical assessment. (7)

The Institute for Clinical Systems Improvement recommends use of at least 1 ADHD-specific rating scale to be administered to parents and teachers. This information should be used as part of the overall historical database for the child and should not be used as the sole criteria for diagnosis of ADHD. (8)

Many sources agree that ADHD-specific rating scales allow a rapid and consistent collection of information from multiple sources. However, the information they provide is necessary, but not sufficient, to make a definitive diagnosis of ADHD. In addition to assisting in diagnosis, checklists can be helpful in monitoring treatment changes once a diagnosis has been established.

TABLE
Descriptive characteristics of abbreviated symptom
checklists for ADHD

Scale                      Minutes        # Items         Age

ACTeRS                      5-10            25           5-12
Parent Version

ACTeRS                      5-10            24           5-12
Teacher Version

DSM-IV SNAP                 5-10            40           6-12

DSM-III-R                   5-10            38           6-12
SNAP

ADHD                          5             18           5-18
Rating Scale-IV

Conners Rating              5-10            27           3-17
Scale, Revised
(1997, Short
Version) (11,12,13)

Effect size

Scale                   Hyperactivity   Inattention   Impulsivity

ACTeRS                       1.5            2.0           NA
Parent Version

ACTeRS                       NA             NA            NA
Teacher Version

DSM-IV SNAP                  NA             NA            NA

DSM-III-R                  3.1-5.1        3.5-4.2       4.0-5.5
SNAP

ADHD                         1.1            1.2           1.1
Rating Scale-IV

Conners Rating               NA             NA            NA
Scale, Revised
(1997, Short
Version) (11,12,13)

Numbers reported in ranges indicate multiple studies.

ACTeRS, ADD-H Comprehensive Teacher Rating Scales; DSM, Diagnostic and
Statistical Manual of Mental Disorders; SNAP Swanson, Nolan, and
Pelham: ADHD, attention deficit/hyperactivity disorder; NA, not
available.

Any factor that inhibits the ability of an individual with asthma to recognize their symptoms appropriately may contribute to treatment delay, “near miss” events, and death during acute severe asthma. The purpose of this study was to investigate the effects of two common features of acute severe asthma-hypoxia and hypercapnia-on respiratory sensation. Sixteen individuals with stable asthma were exposed to three gas conditions (34 minutes each): isocapnic hypoxia (arterial blood O2 saturation of approximately 80%), hypercapnia (increase in end-tidal CO2 of approximately 5-10 Torr), or isocapnic normoxia on 3 separate days. The perceived magnitude of externally applied resistive loads, measured during each gas condition, was reduced throughout hypoxia compared with normoxia, and there was a trend for a progressive decline during hypercapnia. Within the 15-minutes postgas inhalation period, methacholine-induced symptoms of difficult breathing, chest tightness, and breathlessness, measured using modified Borg scales, were 25-30% lower after hypoxia compared with normoxia but were not reduced after hypercapnia. We conclude that 30 minutes of sustained hypoxia and possibly hypercapnia impair sensations of respiratory load and that the effects of hypoxia persist for at least 10 minutes after returning to normoxia.

Hysterectomy is more common in the United States than in other developed countries, with considerable regional variation. Observational studies have reported improvement in sexual function and quality of life after hysterectomy, but this procedure also can result in early ovarian failure, incontinence in later life, and death. In this randomized trial, Kuppermann and colleagues compared a medical and a surgical approach to the treatment of uncontrolled abnormal uterine bleeding in women whose symptoms persisted despite medical treatment for a median of four years.

Premenopausal women 30 to 50 years of age with abnormal uterine bleeding who were treated previously with cyclic medroxyprogesterone were randomized to further medical treatment or hysterectomy and followed for two years. Outcome measures included health-related quality of life, symptom resolution, body image and sexual function, and psychologic distress and well-being.

Sixty-three women who failed to improve with medroxyprogesterone treatment were assigned randomly to receive expanded medical treatment or hysterectomy. The former group received a variety of treatment regimens; in the latter group, some women had abdominal hysterectomy, and some had vaginal hysterectomy. At four weeks, the patients who had hysterectomy experienced a decrease in physical health but had a somewhat higher mental health score than those in the medical groups.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of January 2002. This issue has been reviewed and is acceptable for up to 4.5 Prescribed credit hours. One half hour of these credit hours conforms to AAFP criteria for evidence-based CME clinical content. Credit may be claimed for one year from the date of this issue. When reporting CME credit hours, AAFP members should report total Prescribed credit hours earned for this activity. It is not necessary for members to label credit hours as evidence-based or Prescribed for CME reporting purposes.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4.5 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.