Sunday, August 17, 2008

Nurses can give Botox injections

Botox is booming, here and abroad.

And thanks to a ruling by the Ohio Board of Nursing, the wrinkle-smoothing toxin is likely to help some Ohio medical practices improve their own lines -- their bottom lines.

Last week, Allergan Inc., the pharmaceutical company that makes Botox, said its second-quarter profit rose 6.9 percent, well above analysts' estimates, largely because of robust sales of the facial treatment overseas. Overall, Botox sales jumped 13 percent, to $315.5 million.

A survey by the American Society for Dermatologic Surgery suggests that the use of Botox and dermal fillers is up in the United States, too, in spite of -- or perhaps because of -- the sagging economy and rising unemployment. In a news release detailing the findings, the organization speculated that "baby boomers may be looking to put their best face forward on the interview circuit."

In Ohio, Botox sales could get an additional boost from the recent determination that nurses can give Botox injections, provided that they first undergo special training.

The financial advantage is obvious: By assigning the duty to nurses, medical practices that offer Botox can treat -- and bill -- more patients. And because health-insurance plans typically don't cover elective cosmetic procedures, practices can deal directly with patients and charge, for the most part, whatever the market will bear.

In 2006, the most recent year for which data are available, physicians across the country charged an average of $492 for a Botox injection, according to the American Society of Plastic Surgeons.

Because Botox is a poison, some states explicitly forbid anyone other than a licensed physician to administer the drug.

Before the nursing board ruled on the matter last month, however, Ohio's nurses were operating in uncharted territory. Some were giving Botox shots -- and even determining doses. Others thought the procedure was beyond the scope of practice for nurses and therefore could be performed only by a physician.

"There was no specific prohibition," said Lisa Emrich, manager of the board's nursing practice, education and administrative unit. "It was becoming evident that physicians wanted nurses to do this, and there were no specific guidelines."

The board's decision came in response to a request by Dr. Fernando Colon, a board-certified plastic surgeon and associate medical director of the Skin Center Medical Spa in Gahanna.

Colon argued that allowing nurses to do the procedure would enable him and his colleagues to serve patients more effectively and efficiently.

"A well-trained nurse can continue to repeat this treatment, while I'm at the office doing other things," he said. "In a well-supervised environment, I think it is safe for a nurse to administer these Botox injections."

Colon's request, submitted last year, sparked months of discussion, much of it focusing on potential complications.

"What happens in a bad outcome?" board member Eric Yoon, a nurse practitioner from Springboro, asked at one hearing. "Just call 911?"

Ultimately, the board agreed with Colon but said nurses first must complete a "preceptorship," a period of practical experience and training supervised by a physician, Emrich said.

The board also determined that Botox can't be administered in homes, beauty salons or shopping malls, she said.

Still, some Ohio physicians aren't happy with the decision.

Dr. Michael Sullivan, a board-certified plastic surgeon in Columbus and former director of facial, plastic and reconstructive surgery at the Ohio State University Medical Center, had testified that Botox injections should be left to experienced plastic surgeons or dermatologists.

In unqualified hands, Sullivan said, the drug can cause a number of problems, including muscle weakness, drooping and bruising.

"We're going to hear of more and more complications and potentially deaths, because more and more physicians want to get out of insurance medicine and look at Botox and fillers and some of these quick procedures as a way to create a lucrative practice," he said.

In February, the U.S. Food and Drug Administration reported that Botox had been linked "to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses." The most serious side effects stemmed from the "off-label" use of Botox to treat limb spasms in children with cerebral palsy, the agency said.

Last month, more than a dozen people filed a lawsuit against Allergan in California, where the company is headquartered. The plaintiffs contend that Botox injured them or killed their relatives and that Allergan failed to warn them of potential dangers.

Allergan said Botox has been used safely by millions of people.


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    Big clinics like Skin Vitality need as many specialists as possible because the number of patients is increasing every day.

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