Public Health News
- While flu season may have peaked, further outbreaks may emerge
- Government officials alert physicians to variant Creutzfeldt-Jacob disease symptoms
Clinical News in the Headlines
- Home-based hospice services may improve end-of-life care
- Statins safe for patients with chronic liver disease
- Vasopressin may be more effective than epinephrine in treating sudden cardiac arrest
The Business of Medicine
- Study: For-profit Medicare HMOs don't necessarily deny costly operations
- Health care spending hit record $1.55 trillion in 2002
- Kaiser Permanente plans routine cervical cancer screening with DNA test
- NCI wants physicians' help for booklet on abnormal Pap test results
- Needed: internists to beta test handheld version of PIER
Public health news
CDC director Julie Gerberding, FACP, last week cautiously announced that the severe 2003-04 flu season "may have peaked."
At a press briefing, Dr. Gerberding said that flu outbreaks are now being reported in 38 states, down from 42 states in the previous week. But CDC officials also warned that successive waves of influenza outbreaks have occurred in other flu seasons, often due to different emerging flu strains.
CDC officials quoted in the Jan. 8 New York Times claimed that although flu activity may have peaked in those areas—such as Colorado and Texas—with early outbreaks, other parts of the country may continue to experience escalating numbers of flu cases.
Dr. Gerberding also said that supplies of FluMist—the intranasal, live flu vaccine approved for patients ages 18 to 49 without chronic medical conditions—are still available.
The CDC also announced the launch of its "Germ Stopper" educational campaign, with materials that target children for better flu prevention efforts.
Last week, the CDC reported that 93 children under age 18 with confirmed flu infection have died this season.
According to the Jan. 9 Morbidity and Mortality Weekly Report (MMWR), physicians should test for flu in children with high fevers. Because bacterial pneumonia has complicated 25 of this year's 93 fatalities, physicians should also be aware of drug-resistant bacterial strains in their communities.
A transcript of the CDC press briefing is online at http://www.cdc.gov/od/oc/media/transcripts/t040108.htm.
"Germ Stopper" posters for schools and offices can be ordered online at http://www.cdc.gov/flu/school/
The MMWR report is online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5253a4.htm.
With bovine spongiform encephalopathy (BSE) detected last month in one cow in Washington state, CDC officials have urged physicians to be aware of symptoms of the rare variant of Creutzfeldt-Jacob disease that can result when patients eat meat from BSE-infected animals.
Clinical symptoms of the Creutzfeldt-Jacob disease variant—which has been diagnosed in patients in areas including the United Kingdom—differ from symptoms of classic Creutzfeldt-Jacob disease, which has been diagnosed in the United States.
Experts say the differences include the following:
- The median age at death for the variant form of the disease is 28, compared to 68 for the classic form.
- Patients suffering from the variant form present with prominent psychiatric or behavioral symptoms as well as painful sensory symptoms with delayed neurologic signs. Patients with the classic form, however, present with dementia and early neurologic signs.
- Period sharp waves on EEGs are absent in patients with the variant form, although they are often present in patients with classic Creutzfeldt-Jacob disease.
The CDC is urging physicians to arrange for brain autopsies of all patients with confirmed or suspected Creutzfeldt-Jacob disease.
No patients in the United States are suspected of having the disease variant, according to the Jan. 9 Morbidity and Mortality Weekly Report (MMWR). The CDC report also said that all meat products from the plant that processed the infected cow have been recalled.
The MMWR report is online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5253a2.htm.
Clinical News in the Headlines
Looking back, the families of patients who die at home with home hospice services tend to say that patients receive better treatment for their pain and better communication with caregivers than the families of patients who die in hospitals or nursing homes.
In a study in the Jan. 7 Journal of the American Medical Association, researchers talked to immediate family members of people who died in the year 2000. About two-thirds of patients in the study died in a hospital or nursing home, while one-third died at home.
Family members of patients who died in a nursing home or at home with home health nursing services said their loved ones had more unmet needs for pain management compared to patients who had home hospice services.
In addition, the family members of patients who received home hospice services reported better satisfaction. While 70% of those families rated their loved one's care as excellent, less than 50% of family members of patients who died in other settings gave a similar rating.
Half of the family members interviewed by researchers reported that their loved one did not receive enough emotional support. That figure, however, was much lower when patients died at home while receiving home hospice services.
And families reported more concerns about whether the patient was treated with respect when the last place of care was a nursing home, hospital or home with home health care services than when patients died at home with hospice services.
Not all results were influenced by setting. One-quarter of families, for example, reported concerns with physician communication during medical decision-making regardless of where the patient died.
An abstract of the study is online at http://jama.ama-assn.org/cgi/content/abstract/291/1/88.
A review article published in the January Cleveland Clinic Journal of Medicine recommends prescribing statins to patients with chronic liver disease who need better cholesterol control. The benefits of preventing or treating coronary artery disease with statins, the authors conclude, outweigh the risk of drug-induced liver damage, although patients need to be closely monitored.
At the same time, the authors cautioned that patients with acute liver disease—such as alcoholic hepatitis or acute viral hepatitis—should not be prescribed statins until they recover.
The article points out that there are few trial data related to statin use in patients with chronic liver disease or a history of acute liver disease. However, the authors have found that liver damage from statins is rare in these patients.
The authors include a discussion of different statins and an algorithm for monitoring patients with chronic liver disease who are prescribed statins. Physicians should start patients on low doses of statins, checking their alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels in two weeks.
If patients' AST or ALT levels are two or more times above baseline, statin use should be discontinued, although the authors recommend considering a trial of another statin when those levels return to normal.
If patients' AST or ALT levels remain at baseline or are only mildly elevated, patients' liver enzymes should be monitored monthly for three months. If patients' statin dose needs to be increased, their liver enzymes should be checked in two weeks, then every month for three months after the change.
The journal article is online at http://www.ccjm.org/pdffiles/Russo104.PDF.
A randomized study of nearly 1,200 patients in Europe concluded that vasopressin outperformed epinephrine in resuscitating some patients with out-of-hospital cardiac arrest. Sudden cardiac arrest results in 1,000 deaths a day in the United States.
Subjects received two injections of either vasopressin or epinephrine. Both groups received follow-up epinephrine injections as needed.
Researchers did not find significant differences in the number of patients from either group who survived to hospital admission who had either ventricular fibrillation or pulseless electrical activity, according to the Jan. 8 New England Journal of Medicine (NEJM).
Patients with asytole, however, a condition that accounts for between 20% and 40% of the sudden cardiac arrest fatalities in the United States, fared better when treated initially with vasopressin.
Among the two groups, 29% of asytolic patients were admitted to a hospital compared to 20.3% of the group that received epinephrine. Among the vasopressin group, 4.7% survived to hospital discharge, compared to 1.5% of the epinephrine group.
In addition, among patients in both groups who received follow-up epinephrine injections, those given vasopressin had better admission and discharge rates.
The Jan. 8 New York Times reported that the American Heart Association (AHA) would take the findings into account in considering whether to revise its resuscitation guidelines.
An AHA official pointed out, however, that emergency response teams in Europe include physicians while those in the United States do not. As a result, it is unclear whether American paramedics would be able to achieve the same results.
An abstract is online at http://content.nejm.org/cgi/content/short/350/2/105. (Full text available to subscribers only.)
The New York Times article is online at http://www.nytimes.com/2004/01/08/health/08HEAR.html.
The Business of Medicine
A recent study found that contrary to conventional wisdom, for-profit Medicare HMOs may be just as likely to pay for costly operations and procedures for the elderly as nonprofit health plans.
A study published in the Jan. 8 New England Journal of Medicine examined 1997 data on 12 operations and procedures including heart bypasses and knee replacements for 3.7 million Medicare beneficiaries. Researchers found that that for-profit plans operating under the Medicare+Choice plan during that time were not denying care.
In the for-profit plans, the rates of carotid endarterectomy, cardiac catheterization, CABG and percutaneous transluminal coronary angioplasty were higher than in nonprofit plans. The rates of other common but costly procedures were similar in both types of plans.
Even after adjusting data for enrollee case mix and other plan characteristics, the for-profit plans had significantly higher rates for 2 of the 12 procedures studied, the researchers said. The for-profit plans did not have lower rates on any of the procedures studied.
According to an article in the Jan. 8 Philadelphia Inquirer, the study's lead author said the surprising findings may be related to the fact that both for-profit and nonprofit plans have similar financial incentives and cost-cutting approaches. Another analyst said the for-profits may have been using more preventive care to reduce the number of surgical procedures needed.
The article also pointed out that because the Medicare+Choice plan has changed significantly since 1997, the study's findings may not apply to today's market.
An abstract of the study is online at http://content.nejm.org/cgi/content/abstract/350/2/143. (Full text available to subscribers only.)
The Philadelphia Inquirer article is online at http://www.philly.com/mld/inquirer/business/7657142.htm.
U.S. spending on health care now accounts for nearly 15% of the nation's economy and reached a record $1.55 trillion in 2002, according to figures released by the Bush administration last week.
In an article published in the January/February 2004 issue of Health Affairs, HHS said that health care spending rose by nearly 9.5% in 2002, the largest increase in 11 years. That figure represents an average of nearly $5,500 for every person in the United States.
According to a Jan. 8 article in Modern Physician, spending on physician services accounted for 22% of total health care spending in 2002. Spending on physician services rose 7.7% in 2002 to just under $340 billion. That rate was slightly lower than the 8.6% growth rate of 2001.
Hospital spending, which had increased nearly 4% between 1993 and 2000, increased 9.5% in 2002. According to the Modern Physician article, it was the first time since 1991 that hospital spending grew at a rate faster than overall spending.
The biggest factor in the record-setting increase, however, came from prescription drugs, which rose 15.3% in 2002. Spending on prescription drugs accounted for 11% of health care spending in 2002.
The Modern Physician article is online at http://www.modernphysician.com/news.cms?newsId=1670.
An abstract of the Health Affairs article is online at http://content.healthaffairs.org/cgi/content/abstract/23/1/147. (Full text available to subscribers only.)
Later this year, the nation's largest group-model HMO will begin offering patients routine screening with a DNA test for cervical cancer, in addition to Pap smears.
The DNA test is manufactured by Digene and detects the presence of high-risk types of human papillomarvirus. According to the Jan. 7 San Jose Mercury News, physicians now use the DNA test only when Pap test results are abnormal or inconclusive.
Although the DNA test is 15% more expensive than a Pap test, Kaiser officials believe that combined testing will detect more cases of cervical cancer and reduce the overall frequency of testing. Kaiser's screening guidelines for the combined tests make the following recommendations:
- If both of their test results are negative, patients can wait three years before being tested again.
- If both tests are positive, patients will receive further evaluation.
- Patients with negative Pap results but positive DNA results will be screened annually.
The San Jose Mercury News article is online at http://www.mercurynews.com/mld/mercurynews/7651322.htm.
The National Cancer Institute (NCI) is seeking help from physicians, nurse practitioners and physician assistants to develop an educational booklet for women who have abnormal Pap test results that are found to be non-cancerous.
Health care professionals will be asked to review draft NCI materials and answer questions during a telephone interview. They will also be compensated for their time.
For more information, call 888-249-0029.
Members who have a handheld Palm-based handheld computer with 15 megabytes of free memory (either internal or using a memory expansion card) are invited to participate in a beta test of the new PDA version of the Physicians' Information and Education Resource (PIER).
The test will allow participants to download a PDA version of PIER, ACP's Web-based decision support tool designed for rapid point-of-care delivery of current evidence-based guidance for physicians. The new handheld version of PIER features 220 disease modules. Beta testers will be asked to use the handheld version over the course of a week and to complete a short, eight-question electronic survey.
If you are interested in participating, contact Gloria Klaiman at firstname.lastname@example.org. You'll need to provide your ACP user name exactly as you enter it when accessing either PIER or ACP Online.
For more information, PIER can be found online at http://pier.acponline.org/.
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Copyright 2004 by the American College of Physicians.
A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?
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