In the News for the Week of 10-26-04
Flu vaccine update
- CDC advises on antiviral use
- DEA backs away from pain management guidelines
- Malpractice rates stabilize, but some states hit new highs
Clinical lab resource
- CMS launches new Web site for clinical labs
- White House responds to ACP's prison abuse concerns
- ACP posts revitalization information online
- Physicians in small practices have key online forum
Flu vaccine update
In the wake of the severe influenza vaccine shortage, the CDC last week updated its supply forecast and developed guidelines for using antiviral medications as alternatives for prevention and treatment.
ACP has reminded HHS Secretary Tommy G. Thompson that internists care for the chronically ill and the elderly, two groups vulnerable to the flu, and that it is vital for primary care physicians to have access to vaccine. In a letter sent today, the College asked the HHS to develop "permanent mechanisms" to guarantee a steady supply of flu vaccine to primary care physicians. ACP also urged the HHS to build and maintain a six-month stockpile of prioritized vaccines, and to offer incentives to encourage more manufacturers to produce vaccines.
According to new CDC guidelines, physicians should prescribe amantadine or rimantadine for chemoprophylaxis, and oseltamivir or zanamivir for treatment. Patients at high risk of complications from the flu should be given priority if antiviral supplies run low.
Antiviral medications should also be given to health care workers caring for the elderly or for patients with immunosuppressive diseases, such as HIV/AIDS. Staff who have received vaccine require chemoprophylaxis for two weeks following their shots, while vaccinated and unvaccinated residents should receive chemoprophylaxis during an institutional flu outbreak. People at high risk for complications who live in the same household as someone with the flu should receive antivirals for seven days.
If supplies warrant, the guidelines state that antiviral medication should also be considered for:
- Patients at high risk who do not receive flu shots.
- Patients with immunosuppressive diseases.
- High-risk patients who have been vaccinated for less than two weeks.
- Health care workers involved in direct patient care who were not able to obtain vaccine.
Infected adults and children over age one can also be considered for antiviral treatment. Healthy adults not in any of the high-risk groups are being asked to forgo antiviral use where supplies are limited.
The CDC also assured the public that there would be enough vaccine and antiviral supplies to protect 60 million people during the upcoming season, according to an Oct. 19 HHS news release. That includes an additional 2.6 million doses of vaccine that the pharmaceutical company Aventis Pasteur plans to release in January, as well as up to 3 million doses of MedImmune Inc.'s FluMist nasal spray, which can be given to healthy patients age 5-49.
About 24 million doses of vaccine yet to be distributed will be allocated to high-risk areas, the release said. Millions of additional doses of vaccine will be shipped over the next few weeks.
In related news, the Oct. 21 New York Times reported that the government is advising seniors to get pneumococcal vaccines to help prevent that major complication of the flu. Merck & Co., the only manufacturer of the vaccine, plans to triple production.
Updated information on the flu vaccine shortage, with the latest guidelines and recommendations, is on the ACP's Adult Immunization Initiative Web site.
The College's letter is online.
The CDC's antiviral guidelines are online.
The HHS news release is online.
The New York Times is online.
The U.S. Drug Enforcement Administration (DEA) withdrew its support from recent guidelines on pain management, leaving physicians without official federal guidance on prescribing prescription painkillers.
The DEA made the decision after defense lawyers said they planned to use the guidelines in the drug-trafficking trial of a McLean, Va., physician, according to the Oct. 21 Washington Post. The DEA removed the guidelines from its Web site several weeks after the physician's lawyers attempted to introduce them as evidence. The DEA did not explain the withdrawal except to say that the guideline document was not official policy.
The guidelines, posted on the DEA's Web site in August, were designed to balance the interests of the government—which has in the past charged that some doctors prescribe narcotic painkillers to drug abusers—and pain management specialists, who claim that pain is undertreated nationwide and that physicians are unjustly penalized for aggressive treatment. Pain experts and DEA officials spent more than a year collaborating on the new guidelines.
DEA officials have said they intend to revise the guidelines and publish a new version. In the meantime, the agency has asked at least one academic pain clinic that had posted the guidelines on its Web site to remove them.
The Washington Post is online.
Survey results released last week found that although liability premium rates stabilized in some markets in 2004, physicians in some states are still seeing triple-digit increases.
Most rate increases were between 7% and 25%, compared to rate increases of between 10% and 49% in 2003, according to Medical Liability Monitor, an independent newsletter that conducted the survey and released a report. The newsletter surveyed 46 underwriters—representing 75% of the malpractice insurance market—on rates for internists, general surgeons and ob/gyns.
While rate increases leveled off overall, some specialists reported increases of more than 100%—including internists in Kansas—and are paying record amounts. Internists in Dade County, Fla., had the highest rates nationwide, paying more than $69,000 for coverage, an increase of 5.5%. Internists in Nebraska paid the lowest amount, under $3,300.
The report also found that some companies are continuing to restrict underwriting practices and to impose moratoriums on new business in some markets. In response to rising rates, the report found, some physicians are lowering coverage limits and eliminating certain coverage.
The Medical Liability Monitor's complete 2004 rate survey can be purchased online.
Clinical lab resource
The CMS recently develop a new Web page that offers a comprehensive regulatory and payment resource for practices operating a clinical lab.
The new site contains key information for physicians with clinical labs including billing and payment information; updates on regulations such as CLIA, HIPAA and Stark; correct coding edits; links to educational publications and coverage determinations; and CMS manuals. The site also contains links for demonstration projects involving clinical labs.
The new CMS site is online.
College members have access to an expanded number of clinical lab-related products and services, due to a recent alliance between ACP's Medical Laboratory Evaluation (MLE) proficiency testing service and COLA, a nonprofit lab accrediting organization. More information is online.
The Bush administration has responded to questions raised by the College about alleged abuse of prisoners held under U.S. control in Iraq, Afghanistan and Guantanomo Bay.
In an Oct.12 letter signed by a special assistant to the president, the administration said it condemns the abuses at Iraq's Abu Ghraib prison. The letter further stated that, consistent with College requests for an investigation into U.S. interrogation practices, the administration has ordered a complete accounting of abuse allegations, with investigations now underway to improve detention operations. In interrogating prisoners, the letter says, American personnel "will not compromise the rule of law."
Over the past year, ACP sent two letters to the administration with concerns about alleged mistreatment of prisoners. The letters were prompted by long-standing College ethical policy requiring physicians to speak out against torture.
The full text of the White House's response is online.
The College's letters to the administration are online.
Information about ACP's efforts to revitalize internal medicine is now available in one location on ACP Online.
Members can now read about ACP's national "Revitalization of Internal Medicine" initiative that addresses challenges in the health care environment that affect patient care and compromise the future of primary care. Initiative information grew out of the revitalization summit hosted last year by the College and ACP's collaboration with the Alliance for Academic Internal Medicine, the Society of General Internal Medicine, the Society of Hospital Medicine, the Council of Subspecialty Societies, the American Board of Internal Medicine and other organizations.
The site includes reports on activities and policies related to four revitalization themes, which include repairing the dysfunctional payment system; redesigning medical practice to reduce hassles and improve quality; defining and articulating the value of internal medicine; and educating and training future internal medicine practitioners. Initiative proposals cover medical students, residents, young physicians, internists practicing in hospitals and office settings, general internists and internal medicine subspecialists.
Read more about the ACP revitalization initiative online.
Have questions about coding? Want some ideas for a new compensation plan? Wondering whether to outsource billing?
The ACP Small Practice Discussion Group offers a forum for practices with five or fewer physicians to bounce ideas off each other and learn how other small practices do business. The discussion group is hosted by ACP's Practice Management Center (PMC).
Each month, a featured moderator leads a discussion on a particular topic. At the same time, users start many discussions of their own.
ACP members are invited to visit the site and scan the topics and entries. You can choose to see all messages posted to date or only recent ones.
All entries in the discussion group are accessible only to ACP members, and your e-mail address will not be used for any purpose other than communicating among the discussion group participants. Computer viruses cannot be spread through discussion group access or posting.
Members can reach the discussion group from ACP's home page, the PMC's home page or the Small Practice Discussion Group site.
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Copyright 2004 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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