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American College of Physicians: Internal Medicine — Doctors for Adults ®

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Daily 4-24-10

Internal Medicine 2010 News reports breaking news and events live each day from Internal Medicine 2010 and the American College of Physicians.

Highlights

  • The eyes have it: Recognizing and treating opioid dependence
  • Reform’s impacts on internists explained
  • Incontinence in women a neglected but treatable problem

Breaking news from Internal Medicine 2010

  • ACP announces high-value, cost-conscious care initiative
  • ACP honors outstanding chapter activities with Evergreen Awards

For attendees

  • Saturday's afternoon sessions
  • Eight studies promise immediate change in practice
  • ACP to conduct its Annual Business Meeting
  • Allergy and immunology session canceled

Highlights

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The eyes have it: Recognizing and treating opioid dependence

A patient at your hospital claims she's going through heroin withdrawal and wants treatment. How do you know if she's telling the truth?

Check out her pupils, said Jeffrey H. Samet, FACP, chief of general internal medicine at Boston Medical Center, at a Friday session on managing patients who use illicit drugs.

"Dilated pupils can't be faked," Dr. Samet said, while other symptoms of withdrawal can be seen in the hospital for a host of reasons. These include nausea, restlessness, a heart rate above 100 beats/min, abdominal cramps, sweating, runny nose and watery eyes.

When verified, withdrawal should be promptly treated. Not addressing it can prevent fully dealing with any other medical/surgical condition the patient has. In other words, this is not the time to make the patient go cold turkey.

"Withholding opioids will not cure the patient's addiction, and giving opioids won't worsen the addiction," Dr. Samet said. "You can't expect to cure the dependence during this hospital stay."

Methadone is the best treatment choice for opioid-addicted inpatients, he said. It's available in tablet, oral solution and parenteral forms; has an onset time of 30 to 60 minutes; and lasts about 6 hours for pain and 24 hours in preventing withdrawal.

Start with a 20-mg dose ("People don't stop breathing with this amount," Dr. Samet said) and reassess every two to three hours, giving an additional 5 to 10 mg until withdrawal signs abate.

"Again, rely on the pupils to gauge withdrawal," Dr. Samet said.

Be sure not to exceed 40 mg of methadone in 24 hours, and monitor the patient for central nervous system and respiratory depression. On the following day, give the patient the same total dose you gave in the previous 24 hours.

"Remember, the goal is to alleviate acute withdrawal; the patient will continue to crave heroin," Dr. Samet said.

If the patient's drug test is positive for opiates on the second day of hospitalization, it is not the result of the methadone, he added; as a synthetic opioid, methadone won't show up. The results probably can be explained by residual heroin from before the patient's admission; any morphine the patient was given after admission; illicit opioid use during hospitalization (for example, if the patient left the floor to use); or even ingestion of a poppy seed bagel.

When it's time to discharge the patient, refer him or her to long-term substance abuse treatment, he said. Methadone can't be prescribed in the outpatient world, he added.

There are a few options for treating patients who present to a primary care clinic needing treatment for heroin addiction: referral to Narcotics Anonymous ("a helpful adjunct"); clonidine plus an NSAID plus a benzodiazepine ("not great but not terrible"); naltrexone ("not used much in North America"); buprenorphine maintenance therapy; and referral to a detoxification program, needle exchange, outpatient therapy or methadone maintenance program.

Opioid detoxification doesn't work terribly well; it has low rates of retention in treatment, and fewer than 20% of participants remain abstinent at 12 months. "This is why we push patients to get into opioid-agonist treatment," Dr. Samet said.

In a comprehensive rehabilitation program, methadone treatment has been shown to increase overall survival and treatment retention, and lower illicit opioid use. Maintenance treatment programs are highly regulated and structured, with daily nursing assessment, weekly counseling, random supervised toxicology screening and dosing that's observed daily until a patient "earns" take-home doses, he said.

The limitations to methadone programs are access (five states don't have them at all); inconvenience (daily clinic visits to receive medication); lack of privacy; stable and unstable patients being mixed together; and a stigma among physicians and peers.

An alternative to outpatient methadone that's equally effective is buprenorphine plus naloxone (trade name Suboxone). When taken as sublingual tablets, as intended, the naloxone isn't absorbed. If patients try to crush the tablets and take intravenously, however, the naloxone causes a reaction that will put the patient into acute withdrawal, Dr. Samet said.

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Reform’s impacts on internists explained

“Mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction.”
—Woody Allen

The session began with the darkest of quotes, but Bob Doherty, ACP’s senior vice president for governmental affairs and public policy, actually has a bright outlook on health care reform.

During the Washington update on Friday morning, Mr. Doherty told meeting attendees about the College’s involvement in passing reform, and the likely impacts of the coming changes on internists and their patients.

Incoming College President J. Fred Ralston Jr., FACP, also spoke during the session and summed up the ACP position. “The final bill that passed is imperfect, but we feel it advances College policies on coverage, workforce and the payment/delivery system,” he said.

Expansions in Medicare coverage will likely be some of the first aspects of the new plan to touch internists. As of next January, Medicare will cover a comprehensive health assessment, as well as preventive services that have received an A or B rating from the U.S. Preventive Services Task Force with no cost-sharing from beneficiaries.

“Also, this year you’re going to see the Medicare doughnut hole start being phased out,” said Mr. Doherty. The first step in eliminating the gap in prescription coverage will be rebates paid to patients later in 2010.

In 2014, when the next substantial changes (including individual mandates and state exchanges) kick in, Medicaid coverage will also be expanded. People with incomes up to 133% of poverty will be eligible and Medicaid payments will be increased to match Medicare rates. “That’s real good news,” said Mr. Doherty.

There is a catch, however. The increased payments are only mandated for two years, during which time the federal government will cover them. ACP will push to make the change permanent and Mr. Doherty is optimistic about the chances of success. “Once you establish that as a floor, it’s going to be hard to take it away,” he said.

Other aspects of the reform will also require close attention and possibly continued lobbying from internal medicine advocates. Medicare will give primary care physicians a 10% increase in payments for office, nursing home, home and custodial care visits, provided that such services constitute 60% of a physician’s total Medicare-allowed charges.

That’s good news for some internists, but not necessarily all, said Mr. Doherty. “We have some concerns that this might exclude some of you who do a large number of hospital visits.”

Taken all together, the health reform changes to Medicare result in an expansion of benefits, not the cuts that some were worried about, Mr. Doherty said. The projected cost savings from Medicare are primarily coming from cuts to Medicare Advantage plans and payments to hospitals, he explained.

Another area that may be cut, to the pleasure of internists and their staffs, is paperwork. The bill contains provisions to simplify and standardize private and public health insurance transactions to reduce paperwork for physicians and patients, including claims administration, pre-authorizations, electronic funds transfers, and enrollment procedures.

This provision is important and has been underpublicized, said Mr. Doherty, but he doesn’t guarantee that it’ll make a difference, describing it as a “potential reduction in administrative tasks.”

Attendees at the session were concerned about some issues that weren’t addressed in the health care reform bill, such as malpractice reform and a permanent fix to the problem of the sustainable growth rate (SGR) formula. The SGR continues to frustrate doctors, but there has been some progress, Mr. Doherty said.

The House has passed legislation to repeal the SGR and it has the support of President Obama. Thus far, the repeal hasn’t gotten through the Senate, but they will vote again later in the spring. In the meantime, the College has changed approaches. “We and the AMA decided we would no longer play the game of trying to get votes for short-term fixes,” Mr. Doherty said.

The College will be devoting lobbying attention to some of the aspects of the reform bill that may be less than totally compatible with ACP’s goals, including the new Independent Payment Advisory Board and penalties for not reporting on quality measures.

Mr. Doherty also warned members to get ready to lobby their state governments, as many of the bill’s effects will be determined by state implementation. The College will offer guidance to members on these changes, as well other impacts of health care reform, some of which may be useful information to pass along to patients, Mr. Doherty concluded.

He ended the session on a much more optimistic note than it began. “For the first time in history, the U.S. can say we have a pathway to providing most Americans with coverage.”

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Incontinence in women a neglected but treatable problem

Urinary incontinence in women is a neglected problem, but primary care physicians can play a crucial role in treatment, according to Neil M. Resnick, FACP, of the University of Pittsburgh, who spoke on the topic Friday morning.

Incontinence is extremely common, affecting about 20% to 25% of women before menopause and more than twice that after menopause. Age itself does not cause incontinence, Dr. Resnick noted, but urinary tract changes that accompany age, such as increased involuntary contractions and decreased bladder sensation and contractility, make incontinence more likely.

Workup for incontinence is a multistep process, Dr. Resnick said. At the first office visit, when a patient mentions incontinence, her internist should set her up with a voiding diary and schedule a follow-up visit in a few weeks. At that next visit, in addition to reviewing the diary, the internist should do a history and physical, perform a stress test and measure postvoid residual.

Dr. Resnick said internists should first address possible transient, reversible causes, illustrated by the DIAPERS pneumonic: delirium, infection, atrophic urethritis or vaginitis, pharmaceuticals, excess excretion, restricted mobility, and stool impaction. Treating these will cure incontinence completely in one-third of patients and alleviate it in the remainder, he noted.

Established urinary incontinence, meanwhile, is caused by either storage problems, such as overactive detrusor and stress incontinence, or emptying problems, such as underactive detrusor and urethral obstruction. “In women of any age, 90% of incontinence is in the storage group,” Dr. Resnick said.

Woman who have overflow urinary incontinence, indicated by a postvoid residual of 100 mL or greater, should be referred to a subspecialist. In those with a positive stress test and a low postvoid residual, the presumed diagnosis is stress incontinence, Dr. Resnick said. Those with a negative stress test and a low postvoid residual are presumed to have detrusor overactivity.

If the transient causes have been addressed but the urinary incontinence persists, internists should treat appropriately according to type. For urge incontinence caused by detrusor overactivity, “The cornerstone of treatment is behavioral,” Dr. Resnick said. Physicians should consult the voiding diary and start with bladder retraining, prompted voiding regimens, and urgency suppression methods. Anticholinergic bladder relaxants should be used only as a last resort, Dr. Resnick said. “The only place for drugs is at the very, very, very end, after you’ve done the rest,” he said. Desamino d-arginine vasopressin (DDVAP), he noted, has no role in treating urinary incontinence.

For stress incontinence, conservative treatment works, he said. Overweight women need to lose only 5% to 10% of their weight to achieve a 50% decrease in urinary leakage, according to a recent New England Journal of Medicine article. Tampons and pessaries can be effective, especially for exercise-induced incontinence. Crossing the legs and tightening the pelvic floor before coughing or sneezing can also help, as can Kegels, although women need to do 30 to 50 a day for several months to see results. Surgery can be an effective option, but patients need to understand that “it’s not going to be 100% and it’s not going to last forever,” Dr. Resnick said. Drugs should not be used to treat stress incontinence.

The bottom line, according to Dr. Resnick, is that although incontinence is common, it’s never normal. “The causes are multifactorial,” he said, “but with a positive, persistent approach, we can cure or help the vast majority of the patients that we see.”

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Breaking news from Internal Medicine 2010

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ACP announces high-value, cost-conscious care initiative

Building on its existing foundation of clinical and public policies, the American College of Physicians (ACP) announced plans to provide physicians and patients with evidence-based recommendations for specific interventions for a variety of clinical problems. ACP’s High-Value, Cost-Conscious Care Initiative will assess benefits, harms, and costs of diagnostic tests and treatments for various diseases to determine whether they provide good value—medical benefits that are commensurate with their costs and outweigh any harms.

“Physicians and patients need evidence-based information so they can make the right decision about the right treatment at the right time,” said Joseph W. Stubbs, FACP, ACP’s president. “High-value, cost-conscious care is about eliminating overused and misused medical treatments that do not improve patient health or might even be harmful.”


(From right) Joseph W. Stubbs, MACP, ACP President; Paul G. Shekelle, FACP, PhD, Chair, Clinical Efficacy Assessment Technical Advisory Committee; and Steven E. Weinberger, FACP, Senior Vice President for Medical Education and Publishing, discuss the ACP High-Value, Cost-Conscious Care Initiative.



According to ACP, it is essential to assess benefits, harms, and costs of an intervention to determine whether it provides good value. Evaluation of the costs of an intervention is insufficient to assess value; inexpensive interventions may provide little value, and expensive interventions may provide good value and meet accepted thresholds for clinical effectiveness and cost-effectiveness.

The initiative will include the development of ACP’s High-Value, Cost-Conscious Care Recommendations by ACP’s Clinical Efficacy Assessment Technical Advisory Committee that will be submitted for review and consideration for publication in Annals of Internal Medicine. The effort will address common medical conditions for which inappropriate use of resources is known to be an issue, such as low back pain.

The next edition of ACP’s Medical Knowledge Self-Assessment Program (MKSAP) will also have a focus on optimal diagnostic and treatment strategies, based upon considerations of value, effectiveness, and avoidance of overuse and misuse. Additional phases of the initiative may include patient education materials and curricula for medical students and residents.

“Shared decision-making between physicians and patients is an integral part of high-value, cost-conscious care,” said Steven Weinberger, FACP, ACP’s deputy executive vice president and senior vice president of medical education and publishing. “ACP’s High-Value, Cost-Conscious Care Recommendations will provide evidence about which evaluation and management strategies work best for individual patients.”

According to ACP’s 2009 policy paper, “Controlling Health Care Costs While Promoting the Best Possible Health Outcomes,” the Congressional Budget Office (CBO) estimates that 5% of the nation's Gross Domestic Product—$700 billion per year—is spent on tests and procedures that do not actually improve health outcomes. ACP contends in that paper that savings can be achieved by reducing inappropriate utilization of services and by encouraging clinically effective care based on comparative effectiveness research.

“By eliminating medical treatments that do not directly improve a patient’s health, physicians and patients can significantly reduce waste and preserve high-quality care,” said Dr. Stubbs.

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ACP honors outstanding chapter activities with Evergreen Awards

ACP presented Evergreen Awards to 10 chapters at Internal Medicine 2010. The Evergreen Program provides recognition and visibility to chapters that have successfully implemented programs to increase membership, improve communication, increase member involvement, enhance diversity, foster careers in internal medicine and improve management of the chapter. Following is a list of the chapter winners, the titles of their programs and the categories of submission. For more information on a particular program, contact Suzanne Keller at skeller@acponline.org.

Associates/Young Physicians
New Jersey, for A General and Targeted Needs Assessment for the N.J. Chapter Chief Resident Leadership Program: Success Begins with Planning
The New Jersey chapter embarked on an in-depth needs analysis for the N.J. Chapter Chief Resident Leadership Program to determine baseline leadership perceptions and learning needs of N.J. internal medicine chief residents. The survey results have guided the development of curriculum for the N.J. ACP Leadership Program.

Ohio, for Young Physicians Programming and Events
The Ohio chapter implemented a comprehensive and well-planned program of events that provided leadership development for young physicians. Working with a limited budget, the chapter developed a 16-month planning cycle that helped 32 young physicians advance to Fellowship and recruited 12 to serve on chapter committees and councils.

Tennessee, for Energizing Young Physicians for Active Chapter Membership
The Tennessee chapter expanded the role of young physicians in chapter activities. Beginning with the formation of a Council of Young Physicians, the chapter increased support for LEAD program participation, incorporated young physicians into the Governor’s Council and increased participation in many other targeted events.

Virginia, for Publication of Associate Abstracts
The Virginia chapter collaborated with the University of Virginia Department of Medicine to publish in the University of Virginia Journal of Medicine all 40 research studies and clinical vignettes presented at the chapter’s Associates’ Day. This ongoing partnership provides associates with a published citation, fosters interest in an academic and evidence-based approach to internal medicine, and exposes the educational activities of the College to a broader audience.

Community Service/Volunteerism
North Dakota, for Health Risk Assessment of North Dakota State Legislators
In order to promote prevention and early disease detection, the North Dakota chapter joined with four other North Dakota health care organizations in implementing a health risk assessment program during the biannual session of the North Dakota state legislature.

North Dakota, for Community-Based Diabetes Initiative Program
The North Dakota chapter received a second award for its diabetes prevention program in high-risk communities. Using a highly successful group visit format, the program enabled the chapter to include medical student and resident participation. The chapter also secured outside funding to sustain and grow the program over the past four years.

Education/Communication
Rhode Island, for Patient-Centered Medical Home Summit
The Rhode Island chapter hosted a one-day summit to educate the medical community about the patient-centered medical home model, local efforts to implement the model, and the role of health information technology in this model.

Medical Students
Chile, for Increasing Medical Student Recruitment
Collaborating with the National Scientific Association of Medical Students during the Annual Congress, the Chile chapter increased its reach to medical students by hosting multiple presentations on reasons to be an internist and the benefits of ACP membership. The number of medical students has increased by 39% since the start of this partnership two years ago.

Hawaii, for UH John A. Burns School of Medicine Internal Medicine Interest Group
The Hawaii chapter worked with two other organizations to strengthen the UH John A. Burns School of Medicine Internal Medicine Interest Group (IMIG) through targeted activities and programs. Since the inception of the IMIG, medical student participation has steadily climbed as high as 82%.

Recruitment/Diversity
Japan, for Women’s Committee
The Japan chapter established a women’s committee and increased gender diversity in all chapter committees. As a result of this focused effort, the chapter realized an increase of more than 140% in the number of women members over the past three years.

Special Recognition Award
In addition to the Evergreen winners, ACP is giving special recognition to the Arizona chapter for organizing a leadership retreat to identify short- and long-term chapter goals and create a strategic plan. The Mexico chapter is also recognized for the tremendous efforts of its chapter governor, who established a bimonthly magazine of Annals of Internal Medicine articles translated into Spanish.

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For attendees

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Saturday's afternoon sessions

FFor a list of sessions taking place on Saturday from 4 to 5 p.m., see the spiral-bound "Schedule at a Glance" or see page 73 of the Scientific Program book. The 4 to 5 p.m. sessions begin in the Scientific Program book with "Beyond Expectations: Communicating Interracially and Interculturally."

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Eight studies promise immediate change in practice

The sheer volume of high-impact studies in the past year has been remarkable, and today's Update in General Internal Medicine at 2:15-3:45 p.m. in the North Auditorium will have to move quickly to sort through those that have the greatest effect on clinical practice.

Jack Ende, MACP, and Robert K. Cato, FACP, have spent the past year staying alert for game-changing research that will immediately change how internists practice medicine. Dr. Ende said they relied heavily on ACP's Journal Club PLUS, the online literature service, to tally a running summary of the 50 most important papers, plus a list of the 50 most frequently accessed ones, to develop a short list.

From there, they narrowed the list to a handful of key papers, added a few others and made final selections with the primary criteria being how the studies impact a physician’s practice. Also, Dr. Ende said he selected papers that addressed topics common enough to be worth physicians' time, and that would answer important and longstanding clinical questions.

"Those would be the big-ticket ones that are important," Dr. Ende said, "and hearing their results may well affect what internists do next week for patients. The research should influence the decisions they make every day in your office."

With so many papers in the past year matching the criteria, the two presenters promise to boil the literature down to key points.

"We intend to quickly identify the problem, provide a very concise background on the problem, review existing guidelines and examine how they have changed," Dr. Ende said. "This quick review will be followed by 5 to 10 minutes on the study results, and capped by a take-home point: How should the results affect practice?"

What made the cut?

Mammography
U.S. Preventive Services Task Force recommendations now suggest routinely screening women with no risk factors starting at age 50, performing biannual screening until age 74, and no longer teaching breast self-examination. (Ann Intern Med. 2009;151:716-726.)

Vitamin D
Two studies address the benefits of treating vitamin D deficiency and insufficiency. (BMJ. 2009;339:b3692 and Arch Intern Med. 2009;169(6):551-561)

Important drug interactions
Several studies called attention to concern about proton-pump inhibitors blunting the benefit of clopidogrel in patients with acute cardiac problems. (JAMA. 2009; 301:937-943 and CMAJ. 2009; 180:713-718)

Anticoagulation
A new anticoagulant, dabigatran, will change how internists manage patients with atrial fibrillation. Articles have established safety and efficacy, and the Food and Drug Administration is considering approval. (N Engl J Med. 2009;361:1139-1151)

Arthrosclerosis
Ezetimibe may not be as helpful for arthrosclerosis as internists always assumed it was. (N Engl J Med. 2009;361:2113-2122)

Prostate cancer
Back-to-back studies detail the efficacy of screening for prostate cancer. (N Engl J Med. 2009;360;1310-1320 and N Engl J Med. 2009;360;1320-1328)

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ACP to conduct its Annual Business Meeting

All Members, Fellows, Masters, Associates and Affiliates are invited to attend the 2010 ACP Annual Business Meeting. Current officers will retire and the 2010-2011 Officers, Regents and Governors will be introduced. Annual reports will be presented by Treasurer W. James Stackhouse, MACP, and by Executive Vice President/Chief Executive Officer John Tooker, FACP, MBA. There will be an open forum for members’ questions at the meeting, 12:45-1:45 p.m., Room 203.

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Allergy and immunology session canceled

Saturday's Update in Allergy and Immunology (UD 014) has been canceled. The session was scheduled to be held 7-8 a.m. in the North Auditorium.

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