ACP in the news
- College calls for new health policy framework to improve care
- ACP supports a bill that would reduce taxes on student loans
Access to care
- IOM report calls on U.S. to cover all Americans by 2010
- CBO report: Tort reform won't help control health care costs
Clinical news in the headlines
- Death rates from obesity-related cancers are on the rise
- Highlights from the Jan. 20 Annals of Internal Medicine
- Broader use of beta-blockers could cut costs, improve survival of heart failure patients
- Capsule endoscopy may be better at detecting small-intestine abnormalities than CT scans
- Calcium scores useful in assessing patients' risk for heart disease
Patient education resources
- New diabetes video helps African American patients
ACP in the News
In its annual "State of the Nation's Health Care" report, ACP last week called on the federal government to enact far-reaching provisions to improve health care services, boost access to care and encourage the widespread use of computer technology.
At a press conference held in Washington, College President Munsey Wheby, FACP, pointed out that some progress had been made on health care in the last year. He pointed to a new Medicare drug benefit, which will help U.S. seniors pay for their medications, and stabilized Medicare fees for physicians.
Dr. Wheby said, however, that the country can no longer afford "piecemeal solutions," adding that the Congress and the president need to embrace a more comprehensive approach to health care reform. He pointed out that growing numbers of Americans lack health insurance and safety net coverage, and that fewer physicians are entering internal medicine and primary care specialties.
The College is advocating for the following four actions:
Legislation to provide health care coverage by 2007 for all Americans with incomes of up to 150% of the federal poverty level. Legislation should include guaranteed federal funding for safety net programs, as well as tax subsidies and purchasing arrangements for families and individuals.
Reforms to cut in half by 2007 physicians' paperwork burden from third-party payers.
Resources to allow physicians to make the transition to affordable computer-based health care systems.
Policies to ensure an adequate number of primary care physicians for an aging population.
The College report is online at http://www.acponline.org/hpp/menu/access.htm.
ACP is supporting tax relief provisions in the Higher Education Affordability and Equity Tax Act of 2003 (H.R. 3412) that would reduce the tax burdens of young physicians.
In a Jan. 14 letter to Rep. Philip S. English, ACP joined 48 groups in supporting the bill, which calls for the following:
Expand deductions for student loan interest to allow borrowers to deduct interest payments on their student loans. The bill would increase the income eligibility to claim the full deduction of up to $100,000 adjusted gross income for single taxpayers and up to $200,000 adjusted gross income for joint filers.
Exclude amounts received as part of a scholarship, fellowship or grant from taxable income if used for qualified higher education expenses for undergraduate and graduate recipients.
The letter is online at http://www.acponline.org/hpp/taxrelief_prov.pdf.
Access to care
The Institute of Medicine (IOM) last week issued a report calling on the United States to make sure that all Americans have health care coverage by the end of the decade.
The report, which includes a five-point checklist, echoes some of the recommendations made in ACP's seven-year plan. That document similarly outlines a series of steps to make sure that Americans have access to health care by the end of the decade.
In its report, the IOM concludes that a lack of health insurance leads to nearly 18,000 unnecessary deaths a year among the 43 million Americans who don't have health care coverage. It urges President Bush and the Congress to act immediately and establish a plan to broaden access to care to everyone.
The report, which is the final installment in a series on the consequences of being uninsured, lists the following five principles to achieve that goal:
Health care coverage should be universal.
Health care coverage should be continuous.
Health care should be affordable to both individuals and families.
Any strategy to broaden access to care should be affordable and sustainable.
Health insurance should enhance health and well-being by promoting access to high-quality care.
The report noted that uninsured children and adults suffer worse health and die sooner than people with insurance, a conclusion that ACP reports have reached. People without insurance tend to seek medical care less often than insured patients, and they have worse outcomes for chronic conditions like diabetes, cardiovascular disease and end-stage renal disease.
The report also found that sizable uninsured populations put significant strain on health care providers and institutions that can lead to the loss of resources like physician practices and trauma centers. Large numbers of uninsured can also redirect funds away from core public health programs that help control communicable diseases.
The IOM report is online at http://www.iom.edu/includes/DBFile.asp?id=17732.
More information on ACP's seven-year plan is online at http://www.acponline.org/hpp/afford_7years.pdf.
ACP reports on the health consequences of not having coverage are online at http://www.acponline.org/uninsured/papers.htm.
A new report from the Congressional Budget Office (CBO) said that limiting damages from malpractice lawsuits would not decrease overall health care costs. Those findings contradict the position of many medical organizations.
While evidence indicates that physicians pay less for liability insurance in the 40-plus states that have put limits on tort awards, the report said that those savings can have only "a small direct impact on health care spending." It also concluded that spending on malpractice insurance accounts for less than 2% of overall health care spending.
While advocates of tort reform have argued that limiting awards would reap rewards such as decreasing the practice of defensive medicine, the report said that it found little evidence to that effect.
Legislation in both the House and Senate in 2003 proposed limiting awards for noneconomic and punitive damages. ACP and other medical organizations supported those efforts.
The CBO report is online at http://www.cbo.gov/ftpdoc.cfm?index=4968&type=1.
Clinical news in the headlines
While overall cancer death rates are falling in the United States, the incidence of obesity-related cancers—including some esophageal and liver cancers—are on the rise.
According to annual statistics released last week by the American Cancer Society (ACS), cancer death rates for men with lung, colon and prostate cancer, and for women with colon and breast cancers, fell in 2000 from the previous year. Death rates from colon cancer fell slightly, while those for breast cancer fell from more than 30 per 100,000 in 1995 to less than 27 per 100,000 in 2000.
According to a Jan. 14 Reuters report, however, the statistics also revealed bad news: Lung cancer deaths for women are rising, while obesity-related cancer death rates are also increasing. The report also noted that higher cancer death rates for ethnic groups remains a problem, with differences in death rates for black and white men with colorectal cancer widening since the 1980s.
The overall decline in cancer death rates was attributed to lifestyle changes, such as smoking cessation and better eating habits. At the same time, better surgical procedures and therapeutic options have boosted five-year cancer survival rates from 51% in 1976 to 63% in 2000.
"Cancer Facts & Figures 2004" is online at http://www.cancer.org/docroot/STT/content/STT_1x
Reuters coverage is online at http://www.msnbc.msn.com/id/3960148/.
The following articles appear in today's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online at http://www.annals.org?wkly.
Task force doesn't find enough evidence to recommend thyroid screening for asymptomatic patients. The U.S. Preventive Services Task Force did not find sufficiently strong evidence for or against screening for thyroid disease in patients who have no symptoms of the condition. The task force said that physicians should test for thyroid disease in patients with symptoms of thyroid dysfunction. It also suggested looking for signs of trouble in patients at relative risk for thyroid disease, such as the elderly, post-partum women, people with high levels of radiation exposure and patients with Down syndrome. http://www.annals.org/cgi/content/full/140/2/125
Back pain exercises may reduce lost work days. Researchers in the Netherlands found that a program of graded exercises for low back pain reduced the number of days lost from work more than "usual care" for work-related back pain. Participants exercised under the supervision of physical therapists who insisted that they complete exercises despite pain, graphed progress to provide positive reinforcement and set their own return-to-work dates. http://www.annals.org/cgi/content/full/140/2/77
Research released last week on the economic effects of beta-blockers found that more widespread use of beta-blockers in heart failure patients would likely improve patients' survival rates and reduce Medicare treatment costs.
The study found that the use of beta-blockers improved survival rates by 0.3 years per patient and reduced Medicare per-patient costs by more than $6,000. Those savings result primarily from fewer hospitalizations.
Researchers noted that using beta-blockers increased patients' out-of-pocket drug costs by more than $2,100 over five years. They pointed out, however, that Medicare would save money even if it reimbursed patients for those costs under the new Medicare drug benefit.
The study was sponsored by the Agency for Healthcare Research and Quality, and published in the January issue of the American Journal of Medicine.
Researchers also noted that hospitals and physicians would lose money with wider use of beta-blockers, due to fewer patient fees. They recommended changing financial incentives to reward physicians' use of evidence-based guidelines.
An abstract of the study is online at http://www.cardiosource.com/library/journals/journal/
002934303006041&kwhighligh=. (Full text is available only to subscribers.)
Researchers at the Mayo Clinic in Scottsdale, Ariz., have found that capsule endoscopy may detect small-intestine abnormalities more effectively than other diagnostic tools, such as CT scans, X-rays and barium enemas.
Capsule endoscopy is a procedure that uses a capsule device, approved by the FDA in 2001, that includes a camera lens, battery pack, light source and transmitter. Once patients swallow the tablet-sized device, it transmits images to a recorder as it travels through the digestive track.
According to a study published in the January issue of Radiology, abnormalities were found in 12 out of 19 patients who had both capsule endoscopy and a CT scan, compared to only four abnormalities detected by CT alone.
According to the Jan. 13 Modern Physician, however, low reimbursement rates for the new technology may affect the number of gastroenterologists who use it. In reimbursing capsule endoscopy, Medicare pays less than $190 for the professional component.
According to experts quoted in the Modern Physician article, capsule endoscopy is indicated in 5% of all patients with gastrointestinal bleeding, and only 10% of gastroenterologists are using the device.
A Radiology abstract is online at http://radiology.rsnajnls.org/cgi/content/abstract/230/1/260.
The Modern Physician article is online at http://www.modernphysician.com/news.cms?newsId=1682.
A study has found that assessing patients' coronary artery calcium scores when screening for heart disease may provide a more comprehensive risk assessment than just using Framingham Risk Scores alone.
In a prospective study published in the Jan. 14 Journal of the American Medical Association (JAMA), researchers followed more than 1,000 asymptomatic patients with at least one risk factor for heart disease and no diabetes. Those patients also had coronary artery calcium scores determined by CT scans, in addition to Framingham scores.
After a median patient follow up of seven years, calcium scores of greater than 300 were found to help predict heart disease risk in patients with Framingham scores of between 10% and 20%. Researchers claimed there was an incremental benefit of between 3% and 9% in using high calcium scores to predict a coronary event within 10 years, more than in using Framingham scores alone.
At the same time, researchers also found that a calcium score of zero did not mean that patients had no risk of heart disease. Some patients with no detectable calcium had coronary events, leading the study's authors to comment that many coronary events may be caused by soft plaques that do not contain significant amounts of calcium.
Researchers concluded that calcium scores should be used selectively to help guide clinical decisions for patients who have Framingham scores in the range of 10% to 19%.
An abstract of the JAMA study is online at http://jama.ama-assn.org/cgi/content/abstract/291/2/210.
Patient education resources
A free new patient education video from ACP, "Living with Diabetes: A Guide for African Americans," helps patients deal with a serious health problem facing many African Americans today. The 30-minute video features a testimonial from football star Art Shell, who tells how he manages his own diabetes. Runner and Olympic gold medalist Gail Devers also talks about her experience with family members with diabetes.
The video and accompanying guidebook help patients understand and control diabetes. They also provide tips on preventing serious complications and offer suggestions for healthy eating, exercise and weight management.
During February, which is Black History Month, the video will be shown in its entirety on the following television stations:
Detroit (WWJ-CBS): Saturday, Feb. 21, 2004, 12:30-1:00 p.m.
Philadelphia (KYW-CBS): Sunday, Feb. 15, 2004, 12:30-1:00 p.m.
Washington, D.C. (WJLA-ABC): Saturday, Feb. 28, 2004, 12:00-12:30 p.m.
The video and guidebook are free to ACP members. Shipping costs $5 for one to five items, and $10 for six to 10 items.
For more information on this video and the others in the series, see http://www.acponline.org/college/misc/pe_videos.htm. To order, contact ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600 (M-F, 9 a.m. to 5 p.m. ET). Refer to product #701101930.
You can download the guidebook in PDF format at http://www.doctorsforadults.com/download.htm.
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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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