New ACP benefit
- College launches free online help for recertifying physicians
The business of medicine
- Health care providers gain negotiating clout with insurers
- Bush administration to give Medicare HMOs a 10+% raise
Clinical news in the headlines
- Two-drug combination therapy may help moderate-to-severe Alzheimer's patients
- With fewer outbreaks reported, flu season may be fading
- Nation spends $75 billion on obesity-related health care costs
- Expert panel finds no significant link between suicides and SSRI use in younger patients
- Study questions whether cancer trials help patients
- FDA launches campaign for safer use of OTC pain medications
- CDC: Not enough seniors get strength training
Chronic disease news
- New online journal focuses on chronic diseases
New ACP benefit
ACP is now offering College members free help finding answers to questions in ABIM's five general internal medicine recertification modules.
Members will be only a click away—via the Web—from educational materials that can help them answer each of the 300 self-evaluation process (SEP) questions.
The College has done the preliminary screening to find materials directly related to each question, offering access to many College resources that members may not have on hand.
The online resource draws on the entire body of College products, from articles in Annals of Internal Medicine and College books to modules from the Physicians' Information and Education Resource (PIER) and MKSAP materials.
College materials provide the answers to more than 90% of the questions. For questions not covered by College resources, members are linked to articles through PubMed that will provide the answer.
While the materials help members identify resources, they don't just spell out the answers. Instead, each link will take members to an appropriate Annals article, for instance, or a section of a PIER module.
That should make the links more educational, while dramatically cutting the time members have to spend finding resources to answer questions for recertification.
The new resource is online at www.acponline.org/college/misc/abim_sep.htm. (You need a user name and password for ACP Online to access the materials.)
The business of medicine
The balance of power has shifted somewhat from health plans and insurers to physicians and hospitals in the last few years, according to a new report.
The nonprofit Center for Studying Health System Change (HSC) examined 12 markets in 2002 and 2003. It found that provider groups—particularly hospitals—gained leverage in contract negotiations and secured concessions from health plans, like significant rate hikes and favorable contract terms.
According to a Jan. 22 Modern Physician article, researchers said that physicians have seen their negotiating power rise because of increased consolidation among physicians, consumer demand for large provider networks and a tighter supply of physicians.
The HSC report warned, however, that some of that clout may fade as employers look to health plans to control growing health care costs. It also noted that pay-for-performance initiatives may take away some of providers' newfound leverage.
A summary of the report is online at www.hschange.com/CONTENT/641/.
The Modern Physician article is online at www.modernphysician.com/news.cms?newsId=1722. (Free registration required.)
President Bush is giving Medicare HMOs a record 10.6% pay raise to try to keep them from leaving the Medicare program.
According to the Jan. 20 New York Times, the increase is five times the average 2% increase that Medicare HMOs have received in recent years. Some health plans have said that with their costs rising by 10% and more a year, they would have to leave the Medicare managed care marketplace without a significant increase.
The plans are expected to use the money to enhance benefits or reduce copayments and premiums. They may also use the money to shore up their provider networks by increasing reimbursements to physicians and hospitals.
The New York Times article quoted a CMS official as predicting that the increase, which takes effect March 1, would help prevent some HMOs from leaving Medicare. The Bush administration has said it hopes to enroll more than a third of Medicare beneficiaries in HMOs by 2007.
About 4.6 million U.S. seniors—about 11% of all Medicare beneficiaries—are enrolled in Medicare HMOs. Since the late 1990s, the departure of Medicare HMOs from different markets has left more than 2 million seniors without an alternative to fee-for-service Medicare.
The New York Times article is online at www.nytimes.com/2004/01/20/politics/20MEDI.html. (Free registration required.)
Clinical news in the headlines
Patients with moderate-to-severe Alzheimer's who are already taking donepezil may be able to delay significant loss of function by adding memantine to their drug regimen.
In patients receiving stable doses of donepezil, adding memantine significantly improved cognition, activities of daily life and behavior when compared to patients taking a placebo. The drug combination was well-tolerated.
The authors of a study that appeared in the Jan. 21 Journal of the American Medical Association gave the second drug to patients for a total of 24 weeks.
According to the Jan. 20 New York Times, researchers said they were still unclear about the possible interactions between the two drugs. They were nonetheless optimistic about the ability of the combination to help Alzheimer's patients.
An abstract of the study is online at jama.ama-assn.org/cgi/content/abstract/291/3/317.
The New York Times article is online at www.nytimes.com/2004/01/21/science/21ALZH.html. (Free registration required.)
With only five states now reporting widespread flu activity, experts claim that this year's severe flu season may be at an end.
Widespread activity is still being reported in Pennsylvania, New York, Vermont, Delaware and Minnesota, according to the Jan. 23 Philadelphia Inquirer. As many as 45 states reported widespread influenza outbreaks before Christmas.
The season brought high flu fatalities among children, with 111 deaths attributed to the flu among patients under age 18. Typically, an average of 92 children nationwide die of the flu each year. This year's flu vaccine did not include one viral strain responsible for many of this year's flu cases, a factor in the severity of the season.
The Philadelphia Inquirer article is online at www.philly.com/mld/inquirer/news/nation/7774819.htm.
In flu-related news, Wyeth Pharmaceuticals and MedImmune Inc.—the two companies that market FluMist, this year's new needle-free intranasal vaccine—last week offered 250,000 doses of the vaccine to public health agencies for free. According to the Jan. 21 Washington Post, the offer reflected poor sales of the product, which was launched at the beginning of this year's flu season.
The companies had originally mounted a $25 million promotional campaign and predicted that as many as 5 million doses of the vaccine would be sold. However, only 400,000 doses were sold at the $46 wholesale price.
When injectible flu vaccine supplies began running out, FluMist's manufacturers announced they would sell up to 3 million doses to public health agencies for less than half that wholesale price—a deal that resulted in sales of less than 62,000 doses, according to the CDC.
The Washington Post article is online at www.washingtonpost.com/ac2/wp-dyn/A33882-2004Jan21.
A study released last week estimated that Americans incurred $75 billion in preventable health care costs in 2003 related to obesity. Taxpayers paid half of that national price tag in the form of state, Medicare and Medicaid programs. Obesity-related diseases include cardiovascular disease, type 2 diabetes, gallbladder disease and several cancers.
In cost breakdowns by state, California paid the most in total obesity-related costs, estimated at $7.7 billion. California also had the highest obesity-related Medicare expenditures, at $1.7 billion, while New York had the highest Medicaid expenditures, at $3.5 billion.
Findings were published in the January issue of Obesity Research. According to a CDC press release, the prevalence of obesity among Medicare recipients ranges from 12% in Hawaii to 30% in Washington, D.C. The prevalence among Medicaid recipients ranged from 21% in Rhode Island to 44% in Indiana.
An abstract of the study is online at www.obesityresearch.org/cgi/content/abstract/12/1/18. (Full text available to subscribers only.)
A CDC press release is online at www.cdc.gov/od/oc/media/pressrel/r040121.htm.
A task force of experts from the American College of Neuropsychopharmacology (ACNP) released a preliminary report last week that found no significant evidence that SSRI use in children and adolescents to treat depression led to an increase in suicidal tendencies.
The findings contradicted regulators' conclusions in the United Kingdom, where SSRI use in children and adolescents was banned late last year except for fluoxetine (Prozac).
According to the Jan. 22 New York Times, the ACNP experts reviewed data from 15 clinical trials that included more than 2,000 younger patients. The task force concluded that SSRIs successfully treated depression in younger patients and that suicidal behavior was related to patients' depression, not their medications.
Experts stressed that their findings were preliminary. They also recommended that physicians prescribing SSRIs to younger depressed patients should ask about any thoughts or plans patients may have to commit suicide.
The New York Times reported that the task force did not have access to some data used in the United Kingdom. Critics also pointed out that the report was not based on a meta-analysis, which is now being done by other researchers, and that the majority of experts on the task force had "significant financial ties" to drug companies.
FDA hearings on SSRI use in younger patients are scheduled for Feb. 2.
An executive summary of the ACNP report is online at www.acnp.org/exec_summary.pdf.
The New York Times is online at www.nytimes.com/2004/01/22/health/22DEPR.html. (Free registration required.)
A new study casts doubt on the belief that most cancer patients are helped by enrolling in clinical trials.
After examining the outcomes of patients enrolled in clinical trials detailed in 24 previously published studies, researchers found that in only a few instances did the health of the patients improve. The report appeared in the Jan. 24 issue of The Lancet.
According to a Jan. 23 New York Times report, the biggest health improvement was seen in two types of studies: trials involving children and studies of adults with blood cancers.
In an interview, researchers said that even those results were due to specific conditions. They said they examined pediatric studies from a period when researchers were making tremendous advances in treatment, while the adult trials targeted forms of cancers that tend to respond to treatment.
The Lancet article concluded that despite a widespread belief that clinical trials help patients, there are insufficient data to support that belief. They said that physicians need to communicate this uncertainty to patients when recommending they enroll in a clinical trial.
The Lancet article is online at www.thelancet.com/journal/vol363/iss9405/full/
llan.363.9405.original_research.28420.1. (Free registration required.)
The New York Times article is online at www.nytimes.com/2004/01/23/health/23CANC.html. (Free registration required.)
The FDA last week began a national educational campaign to promote the safer use of over-the-counter (OTC) pain medications. The campaign, which includes public service announcements and patient brochures, is aimed at reducing accidental overdoses from acetaminophen and complications of non-steroidal anti-inflammatory drugs (NSAIDs).
According to the Jan. 22 Associated Press, more than 56,000 patients a year visit emergency rooms after overdosing on acetaminophen, which can cause liver damage and death. Overdoses result when patients take higher-than-recommended dosages, or when they combine products that all have the same active ingredient.
Campaign material states that patients should avoid using multiple medications, and that the risk of liver damage from acetaminophen is even higher in patients who use OTC medications containing acetaminophen if they drink three or more alcoholic beverages a day.
Patients also are at higher risk of stomach bleeding from NSAIDs if they are over 60, take blood thinners or steroids, or have a history of stomach bleeding.
FDA campaign materials are online at www.fda.gov/cder/drug/analgesics/default.htm.
An FDA press release is online at www.fda.gov/bbs/topics/NEWS/2004/NEW01008.html.
Associated Press coverage is online at www.msnbc.msn.com/id/4031091.
CDC survey results released last week found that only 11% of patients age 65 and older do strength training exercises two or more days a week. Strength training—which is also known as resistance training—is recommended for older patients to reduce their risk of fractures and falls and improve their capacity to live independently.
According to the CDC, more programs should be designed for seniors to allow them to get recommended strength training exercise. Seniors need programs that are affordable and accessible, as well as encouragement to do strength training in their homes using videos or exercise guides.
The findings, which were published in the Jan. 23 Morbidity and Mortality Weekly Report (MMWR), also included strength training recommendations for older patients from the National Institute on Aging. Those recommendations included:
If weights are used, start with one-to-two pound weights and increase weight amounts over time.
Do exercises that work the major muscle groups, as well as activities to improve grip strength.
Perform one set of eight to 15 repetitions of each exercise, then a second set of the same exercises.
Rest before repeating sets, and stretch after finishing exercises.
The MMWR article is online at www.cdc.gov/mmwr/preview/mmwrhtml/mm5302a1.htm.
Chronic disease news
The CDC has launched a free, peer-reviewed online-only journal that focuses on chronic disease.
The January 2004 issue of Preventing Chronic Disease: Public Health Research, Practice and Policy features a video about tobacco control programs and studies that find many diabetics do not receive flu or pneumonia vaccinations.
The journal says its goal is to "promote dialogue between researchers and practitioners on research findings and practical experience." It is intended for researchers of chronic disease prevention and health promotion, and for public health practitioners.
The journal is online at www.cdc.gov/pcd/.
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Copyright 2004 by the American College of Physicians.
A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?
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