In the News for 4-23-09
- Expert urges rethinking first-line treatment for hypertension
- Governors tackle reimbursement, advocacy and post-grad education
- Regents act to boost public view of primary care
- Harold Sox to retire as editor of Annals of Internal Medicine
Breaking news from Internal Medicine 2009
- Check out our blog for frequent meeting updates
- Tweet the meet: Twittering from Internal Medicine 2009
- Update in Cardiology weighs in on current controversies
- Ripped from the headlines: Update in Women's Health
ACP Internal Medicine 2009 News reports breaking news and events live each day from Internal Medicine 2009 and the American College of Physicians.
Expert urges rethinking first-line treatment for hypertension
There was hypertension and hyperlipidemia, but no hyperbole during Wednesday's precourse on Advances in Therapy. Leonard A. Mankin, ACP Member, presented recent research findings on cholesterol and blood pressure and offered some recommendations for treatment.
What is most needed, he said, is more treatment. “Fewer than half of the patients who qualify for lipid treatments are receiving them, including those at highest risk.” The statistics for hypertension are even worse. While a third of U.S. adults have high blood pressure, only 37% of those with the condition have it under control.
While no one would debate the need for treatment, his recommendations on how to treat might be a little more controversial, Dr. Mankin warned. Based on recent research, including the ACCOMPLISH trial, he favors chlorthalidone over hydrochlorothiazide as the first-line diuretic of choice. Although hydrochlorothiazide is more widely prescribed, chlorthalidone is more potent and is supported by better evidence. “It’s very unclear why chlorthalidone went out of fashion,” Dr. Mankin said. “I think we should do away with hydrochlorothiazide as our diuretic of choice.”
Beta-blockers should no longer be first-line therapy either, since research has proven them to be less effective than other options for blood pressure control, Dr. Mankin noted. “For years, recommendations have been coming out and yet these agents are still being used.” The drugs continue to be good options for patients with heart failure, myocardial infarction and angina pectoris.
On the less-proven side, Dr. Mankin reviewed new non-drug therapies for hypertension. The first was a device that looks similar to an MP3 player and helps patients regulate their breathing. It costs $278 and was effective in manufacturer-sponsored trials. “It could work for patients who are unwilling to take medications but willing to spend some money,” said Dr. Mankin. “It may be the only time when technology lowers blood pressure.”
He was more excited about a new surgery—percutaneous renal sympathetic denervation. Earlier this year, researchers published in the Lancet about their success using catheterization to ablate renal arteries and lower patients’ blood pressure. “This shows promise for the future,” said Dr. Mankin. “I’m very hopeful that we could take a 25-year-old with hypertension, give them a 38-minute procedure and control their blood pressure for years, if not life.”
In hyperlipidemia, the focus is still on drugs. The real question is how many people should be taking cholesterol medications. “To paraphrase, should we put statins in the water?” Dr. Mankin asked. He wasn’t ready to answer that question with a definite yes or no, but did note that he uses statins in many elderly patients and could see some merit in giving the drugs to younger patients. “I think further trials are needed,” he concluded.
Further research is also needed to determine the value of testing for C-reactive protein, Dr. Mankin said. For now, he sees it as most useful when a physician is on the fence about the need for, or appropriate dosing of, statins.
Governors tackle reimbursement, advocacy and post-grad education
The Board of Governors voted Wednesday on a number of issues ranging from reimbursement to plant-based diets to prisoner abuse.
They also acted to stem the impending shortage of primary care physicians by recommending the Regents collaborate with the American Osteopathic Association in finding ways to increase the number of medical students who choose internal medicine residencies and careers as general internists.
“This is consistent with ACP’s mission to work in collaboration with family practice physicians and osteopaths,” noted Mark Mayer, FACP, Governor for Ohio.
On a related note, the Governors sought to make it easier for hospitalists to switch to office-based practice, by asking the Regents to identify and develop a post-graduate track to update and/or reeducate hospitalists about outpatient medical practice issues.
Board members also asked the Regents to provide medical students with increased advocacy opportunities, such as health policy fellowships and accolades for involvement in ACP or local/national health advocacy efforts.
“Those of us who have been to Leadership Day know that our young people have a bigger impact than us (older physicians),” said Richard Kasama, FACP, Governor for New Jersey. “The legislators recognize them as the future.”
Other measures which passed included:
- Support for collaboration between human and veterinary medicine, including cross-species disease surveillance;
- Pursuit of adequate reimbursement for all vaccines administered according to Advisory Committee on Immunization Practices (ACIP) guidelines; and
- A request that liability insurance carriers consider different insurance rate structure criteria for internists who solely practice outpatient care.
After vigorous debate and a close vote, the Governors decided against a measure which promoted education and legislation geared toward making a plant-based diet more available and affordable to the general public. Richard Engel, FACP, Governor of Maine, said the measure was important to the overall goal of promoting a healthy diet among patients.
“It’s the right of the U.S. population to have economic access to a healthy diet… which is more expensive than a processed diet,” Dr. Engel said.
But Jim Foody, FACP, of Northern Illinois felt the measure put the College “in an awkward position of looking silly on an issue,” by seeming to endorse a vegetarian diet.
“Vegetarianism is a quasi-religious dogma we shouldn’t be associated with,” Dr. Foody said. “(This measure) also strikes at industrial farming, which is complicated.”
The Governors also voted to refer several issues for further study, including:
- Encouraging the editors of high-impact medical journals to explicitly address the benefits and costs of treatments in articles about therapy;
- Developing a work plan to reverse the CMS-enacted reduction in reimbursement for dual-energy x-ray absorptiometry (DXA);
- Developing a mechanism for winning Associate abstracts to be published in an online supplement to the Annals of Internal Medicine. Such a measure could serve as a recruitment tool, since one must be a College member to submit an abstract, several Governors noted;
- Disclosing, in promotional and registration material, the dollar amount of pharmaceutical support to conduct any ACP meeting; and
- Initiating or supporting an investigation into the recent role of physicians in preventing, detecting and halting abuse or torture of military and CIA detainees.
Regents act to boost public view of primary care
The Board of Regents voted Monday on several measures to enhance public and political perception of primary care and/or general internal medicine. One measure supports legislation that would fund research on the value and cost-effectiveness of primary care, while another calls for monitoring the national news for negative coverage of primary care and establishing a prompt media counter-response.
The Regents also approved a policy monograph aimed at improving the FDA's regulation of prescription drugs. Recommendations include increasing the FDA's funding and ability to regulate drugs made outside the U.S.; expanding the FDA's regulatory authority in the design of pre-approval trials and studies; prohibiting the practice of bundling drugs to limit marketability and availability; and improving the adverse events reporting system.
In addition, the Regents recommended giving the FDA authority to require that newly approved drugs have a special symbol on their labels to increase public awareness that they are new, and to limit direct-to-consumer ads for the first two years after a drug's approval.
The Regents also voted to:
- Endorse a curriculum on cardiovascular disease prevention, which the College created in conjunction with the American College of Cardiology Foundation and the American Heart Association;
- Promote separate payment for Medicare-covered preventive services rendered during a Welcome to Medicare visit or a "medically necessary" visit and clarify Medicare rules about the role that counseling and coordinating care should play in billing for the visits;
- Publicize to College members the possible dangers of signing ambiguous forms from health insurers, and highlight cases where companies implemented misleading or fraudulent policies. The Regents will also work with other medical societies to inform regulators about any fraudulent representation by insurers;
- Establish benchmarks for reasonable health insurance administrative costs, and explore means for reducing and controlling those costs. The Regents will also set guidelines on the percentage of premium that should be spent on delivering patient care;
- Approve a plan to increase College membership, which would include offering trial memberships of up to nine months, offering online memberships at a reduced rate, lowering the introductory dues rates for new members and increasing the number of joint dues discounts with subspecialty societies;
- Approve a position paper on privacy issues surrounding the use of health information technology;
- Advocate for an amendment to the Controlled Substance Act that would allow for secure electronic transmission of controlled substance prescriptions; and
- Send a formal response letter regarding the Institute of Medicine’s latest report and recommendations on resident duty hours. The letter expresses concern that a proposed five-hour protected sleep period will increase patient hand-offs, and that limiting in-hospital night shifts to four consecutive nights will make scheduling difficult.
Harold Sox to retire as editor of Annals of Internal Medicine
Harold C. Sox, MACP, noted internist, author, teacher, and nationally renowned expert on medical decision making, will retire in July as editor of Annals of Internal Medicine, the official journal of the College. A new editor has not yet been named.
Dr. Sox, a former president of ACP, became editor of the journal in 2001. During his tenure, he brought more original research to the journal, emphasizing quality improvement, clinical policy, and evidence-based medical decision-making. Dr. Sox recently was named to chair the Institute of Medicine’s Committee on Comparative Effectiveness Research Priorities. He will lead a panel of nationally renowned medical experts in making recommendations to the Obama administration about priorities for research funding under the American Recovery and Reinvestment Act of 2009.
“I and my colleagues have focused a great deal of energy on identifying and publishing top-notch comparative effectiveness research, as I have always believed that it provides a foundation for physicians and patients to make the best possible treatment decisions," said Dr. Sox said in a press release. "I expect great things to happen under the leadership of my successor.”
- View a video presentation of special remarks by Dr. Sox
Breaking news from Internal Medicine 2009.
Check out our blog for frequent meeting updates
Go to ACP Internist's blog to read staff reports from each day's sessions at Internal Medicine 2009.
A precourse on diabetes care had some interesting tips on monitoring in diabetes, our writer reports, including the most common reason that patients' finger-sticks are inaccurate, why anemia can make A1c test results inaccurate, and the newest big thing in diabetes monitoringreal-time continuous glucose monitors. Also, link to the National Institute on Drug Abuse's new online screening tool for substance abuse.
Tweet the meet: Twittering from Internal Medicine 2009
ACP will Twitter from Internal Medicine 2009. Join us at twitter.com/ACPinternists.
Vineet Arora, FACP, will use her Twitter feed to digest events from Internal Medicine 2009. Using the alias @FutureDocs, she usually sends tweets about medical education for students and residents. Subscribe, or check out her Twitter page.
Update in Cardiology weighs in on current controversies
For their Update in Cardiology (course handout: handouts are available to attendees of Internal Medicine 2009) session at 11:15 a.m. today in the Marriott Salon F, the co-moderators prepared the old fashioned way: they pored through piles of journals from the previous year.
Moderator Laura Wexler, FACP, associate dean for admissions and student affairs at the University of Cincinnati College of Medicine, and co-moderator Eli Roth, MD, medical director of Cincinnati's Sterling Research Group, will cover the latest in heart failure, prevention, imaging, arrhythmias, coronary artery disease, valvular heart disease and interventional cardiology—issues of particular interest to the internist, Dr. Wexler said.
At the top of the list will be discussion of JUPITER—arguably the most important cardiology study to come out this year—which found patients with high C-reactive protein levels but normal LDL levels can significantly benefit from statins.
Several of the featured studies are essentially progress notes on issues that continue to perplex internists, such as the variation in patient responses to clopidogrel (Plavix), a critical drug for preventing restenosis of stents. Recent studies suggest these variations are genetically based.
Dr. Roth will update internists on the ongoing issue of whether statins cause cancer in patients with low LDL cholesterol, as well as when internists should use non-invasive CT angiography or invasive coronary angiography to look at patients' coronary arteries.
The moderators also sifted through the new American Heart Association/American College of Cardiology guidelines released in the last year, and picked the ones they thought were most relevant to the internal medicine community, Dr. Wexler said. A list of these will be part of a handout available to session attendees.
In addition, the moderators plan to weigh in on a lot of current debates in cardiac medicine—what Dr. Wexler likes to call the "should you or shouldn't you" controversies. Examples are whether an internist should (or shouldn’t) always use brain natiuretic peptide (BNP) levels when diagnosing heart failure, and whether she should refer patients with extensive coronary disease for multiple stenting (instead of CABG).
Ripped from the headlines: Update in Women's Health
If you've provided primary care to women lately, you've probably heard questions about vitamin D levels, HPV testing and folic acid supplementation.
At the Update in Women's Health (course handout: handouts are available to attendees of Internal Medicine 2009) today at 2:15 p.m. in Room 204 A, moderator Janet Pregler, FACP, will answer—or at least provide the latest information about—these and other hot questions in medicine for women.
During the session, Dr. Pregler and co-moderator Carolyn J. Crandall, FACP, will review the latest research on osteoporosis, breast ultrasounds, hormone therapy, and treatment of sexual dysfunction, among other topics.
Vitamin D has been one of the hottest subjects in recent medical research affecting women, she noted. Session attendees will review a 2008 study which linked vitamin D concentrations to hip fracture in women age 50 to 79. But is it worthwhile to screen women to find out their levels? And should physicians make a major push for women to take vitamin D supplements?
For example, researchers learned last year that taking folic acid and B vitamins did not reduce high-risk women's likelihood of developing cardiovascular disease. The session will review the details of that study.
The moderators will also uncover the data behind the discussion on using HPV tests to screen for cervical cancer. Co-screening with a Pap test and an HPV test is great when both come up negative and indicate that a woman can wait three years for her next screen, she explained. But a positive HPV result with a negative Pap can mean more invasive testing for women who might not need it.
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Look back at Internal Medicine 2009 coverage
ACP Internist created a photo gallery of scenes from Internal Medicine 2009.
Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, 2nd Edition
This new edition reflects recent clinical and social changes and continues to present the important issues facing practitioners and their LGBT patients. Read more about the Guide. Also see ACP’s recent policy position paper on LGBT health disparities.
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