correspondence

1. Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and sur- nual report 2002. Washington, D.C.: National Committee for Qual-
vival among Veterans Affairs beneficiaries. N Engl J Med 2003;349: ity Assurance, 2003.
1637-46. 3. Hewitt Health Value Initiative. Lincolnshire, Ill.: Hewitt, 2003.
2. Thomas RJ, Palumbo PJ, Melton LJ III, et al. Trends in the mor-
tality burden associated with diabetes mellitus: a population-based
study in Rochester, Minn., 1970-1994. Arch Intern Med 2003;163:
445-51.
dr. fisher replies: The evidence supports Dr. Pearl’s
3. Marston BJ, Plouffe JF, File TM Jr, et al. Incidence of community- assertion that the adoption of an integrated ap-
acquired pneumonia requiring hospitalization: results of a popula- proach to care is a path toward improving the qual-
tion-based active surveillance study in Ohio. Arch Intern Med 1997;
157:1709-18.
ity of care for patients with chronic disease.1 We
4. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the should not kid ourselves, however, by assuming that
incidence of and survival with heart failure. N Engl J Med 2002;347: the adoption of such models will provide cost sav-
1397-402.
5. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality
ings in and of themselves. The local capacity of the
in all patients on dialysis, patients on dialysis awaiting transplanta- health care system is the major determinant of over-
tion, and recipients of a first cadaveric transplant. N Engl J Med all utilization.2 Unless beds are closed, or physicians
1999;341:1725-30.
laid off, reduced utilization by those enrolled in a
management program for chronic disease will lead
to the editor: In his editorial, Fisher1 argues that to compensatory increases in utilization by other pa-
there may be an inverse relationship between qual- tients. It is little wonder that constraints on capacity
ity and quantity in health care. However, I believe are the means whereby both the VA and staff-model
that the improved clinical outcomes in the VA study health maintenance organizations such as Kaiser
resulted not from lower expenditures but rather Permanente have achieved their efficiency.3
from a third set of changes, including increased in- Moreover, the additional utilization among res-
tegration of facilities, creation of new centers of ex- idents of high-capacity regions in the United States
cellence, and implementation of an advanced in- is devoted to services that do not appear to improve
formation-technology system. health or the quality of care and that may make things
It has been shown that comprehensive health worse.4,5 But integration is not enough. Until we ad-
care systems provide superior outcomes with re- dress the challenge posed by the overuse of supply-
spect to quality and encourage more efficient use sensitive services, we are unlikely to achieve both the
of resources. For example, in California, the physi- quality and efficiency achieved by systems such as
cians of Kaiser Permanente have lowered the mor- Kaiser Permanente.
tality from cardiovascular disease among their pa- Elliott Fisher, M.D., M.P.H.
tients to 30 percent below that among patients in Veterans Affairs Outcomes Group
the surrounding community,2 while providing care White River Junction, VT 05009
at a relatively low cost.3 Superior quality is attained 1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary
not by doing less, but by implementing integrated care for patients with chronic illness: the chronic care model. JAMA
systems of care, supported by advanced informa- 2002;288:1909-14.
2. Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital re-
tion-technology systems. Whereas the VA could do admission rates for cohorts of Medicare beneficiaries in Boston and
this by directive, accomplishing this important goal New Haven. N Engl J Med 1994;331:989-95.
will prove more difficult for the nation as a whole. 3. Kronick R, Goodman DC, Wennberg J, Wagner E. The market-
place in health care reform: the demographic limitations of man-
Robert Pearl, M.D. aged competition. N Engl J Med 1993;328:148-52.
4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pin-
Permanente Medical Group der EL. The implications of regional variations in Medicare spend-
Oakland, CA 94612 ing. 1. The content, quality, and accessibility of care. Ann Intern Med
2003;138:273-87.
1. Fisher ES. Medical care: is more always better? N Engl J Med 5. Idem. The implications of regional variations in Medicare spend-
2003;349:1665-7. ing. 2. Health outcomes and satisfaction with care. Ann Intern Med
2. Making a difference: recognizing and rewarding excellence. An- 2003;138:288-98.

Gout
to the editor: In discussing treatment options for
gout (Oct. 23 issue),1 Terkeltaub omitted the emerg-
ing role of fenofibrate. This fibric-acid derivative is
used to treat various forms of hyperlipidemia and
has recently been shown to prevent the progression
of coronary artery disease.2 Fenofibrate is unique
among the fibrates because of its uricosuric proper-
ties and has been shown to lower serum urate lev-

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 The new england journal of medicine

els by 19 percent in men with gout receiving es- in persons with the metabolic syndrome. However,
tablished therapy with allopurinol.3 Remission of maximal lowering of serum urate levels by fenofi-
clinical episodes of gout over several years has also brate appears to be low, relative to that produced by
been reported.4 conventional allopurinol, probenecid, or benzbro-
Furthermore, although this notion is contro- marone treatment regimens. Moreover, the adjunc-
versial, high urate levels may be an independent tive effects of two months of fenofibrate for serum
risk factor for coronary artery disease.5 Fenofibrate urate lowering in men with gout and hypertriglyc-
might therefore have a particularly useful role in eridemia who were already receiving either allopu-
insulin-resistance syndromes, such as type 2 diabe- rinol or benzbromarone averaged only 15 percent
tes, because of its additional uricosuric effect. in a controlled trial.1
Alastair L. Hepburn, M.R.C.P. The role and efficacy of fenofibrate in the long-
term management of hyperuricemia and in reduc-
Imperial College
London W12 0NN, United Kingdom ing tophus size and arthritis-attack frequency in
a.hepburn@imperial.ac.uk gout remain to be established by adequately de-
Michael D. Feher, M.D., F.R.C.P. signed trials of sufficient duration, as opposed to
Chelsea and Westminster Hospital limited case reports.2 It is not yet clear how renal in-
London SW10 9NH, United Kingdom sufficiency affects fenofibrate’s urate-lowering ca-
Editor’s note: Dr. Feher reports having received re- pacity. Furthermore, precautions used when initiat-
search support from Fournier Pharmaceuticals, ing primary treatment with uricosuric agents (e.g.,
probenecid) in order to lessen the risk of urolithi-
which manufactures fenofibrate.
asis appear to be appropriate for instituting feno-
1. Terkeltaub RA. Gout. N Engl J Med 2003;349:1647-55. fibrate therapy in persons with hyperuricemia.
2. Effect of fenofibrate on progression of coronary-artery disease
in type 2 diabetes: the Diabetes Atherosclerosis Intervention Study, a
Whether hyperuricemia is an independent factor
randomised study. Lancet 2001;357:905-10. [Erratum, Lancet 2001; in atherogenesis remains unclear. Therefore, it ap-
357:1890.] pears to be premature to advocate the use of feno-
3. Feher MD, Hepburn AL, Hogarth MB, Ball SG, Kaye SA. Fenofi-
brate enhances urate reduction in men treated with allopurinol for
fibrate for targeted management of asymptomatic
hyperuricaemia and gout. Rheumatology (Oxford) 2003;42:321-5. hyperuricemia in patients with the metabolic syn-
4. Hepburn AL, Kaye SA, Feher MD. Long-term remission from drome.
gout associated with fenofibrate therapy. Clin Rheumatol 2003;22:
73-6. Robert A. Terkeltaub, M.D.
5. Fang J, Alderman MH. Serum uric acid and cardiovascular mor- Veterans Affairs Medical Center
tality: the NHANES 1 Epidemiologic Follow-up Study 1971-1992. San Diego, CA 92161
JAMA 2000,283:2404-10.
1. Takahashi S, Moriwaki Y, Yamamoto T, Tsutsumi Z, Ka T, Fuku-
chi M. Effects of combination treatment using anti-hyperuricemic
dr. terkeltaub replies: I concur with Drs. Hepburn agents with fenofibrate and/or losartan on uric acid metabolism.
Ann Rheum Dis 2003;62:572-5.
and Feher regarding the potential role of fenofibrate 2. Hepburn AL, Kaye SA, Feher MD. Long-term remission from gout
for treating both hyperlipidemia and hyperuricemia associated with fenofibrate therapy. Clin Rheumatol 2003;22:73-6.

Case 5-2003: A 16-Year-Old Girl with a Rash and Chest Pain

to the editor: A patient such as the one described skin lesions in lupus are photosensitive. The case
in Case 5-2003 (Feb. 13, 2003, issue),1 who has a
rash and a positive test for antinuclear antibodies
(in a homogeneous pattern), is usually considered to
have systemic lupus erythematosus unless another
diagnosis is confirmed. It is reported that the pa-
tient’s level of total hemolytic complement was
normal but that her levels of C3 and C4 were low.
These laboratory findings are incompatible, since
typically, if the levels of C3, C4, or both are low, the
level of total hemolytic complement is also low. Most
report indicates that the patient was not exposed to
sunlight; however, exposure to fluorescent light can
also cause rashes. Usually, I counsel patients to avoid
being exposed to the light of fluorescent bulbs, but
more important, I advise them to use sunscreen.
Peter H. Schur, M.D.
Harvard Medical School
Boston, MA 02115
1. Case Records of the Massachusetts General Hospital (Case 5-
2003). N Engl J Med 2003;348:630-7.

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