In the News for the Week of 11-9-04
- Physicians get mixed results in state malpractice initiatives
Clinical news in the headlines
- Medicare to boost overall physician payments by 4% in 2005
- CMS will launch cancer care demonstration project
- IOM warns about ongoing threats to rural health care
- College supports new WHO initiative on HIV/AIDS
- College EVP taking part in election results roundtable
- Wanted: internist to help brief Congress on language issues
Physicians get mixed results in state malpractice initiatives
Voters in four states last week sent mixed signals about the need for medical liability tort reform.
Voters in Nevada approved removing exceptions to an existing $350,000 state cap on noneconomic damages, while those in Florida passed limits on attorneys' fees. However, voters in Wyoming and Oregon defeated physician-backed proposals to cap noneconomic damages in those states.
And while Florida voters approved restricting attorney fees to 30% of malpractice settlements, they also approved two attorney-backed ballots, according to a Nov. 4 Associated Press story. One measure will give the public access to records on physician medical errors, while the other gives the state the ability to revoke the license of any physician who loses three malpractice suits. (Physicians' licenses cannot be revoked for three malpractice settlements. The Florida Medical Association has claimed the measure will lead innocent physicians to rush to settle.)
The measure passed in Nevada will also revise malpractice payments for multiple defendants and cap administrative costs and attorney fees. And voters in Nevada defeated two attorney-backed ballots. One would have eliminated the state's noneconomic damage cap if malpractice premium rates weren't reduced by at least 10% within a year, while the other would have fined attorneys who file frivolous suits.
The Associated Press is online.
For more information, see "Doctors take tort reform fight directly to voters" in the October ACP Observer.
In another health care-related measure, California voters approved spending $3 billion to fund embryonic stem cell research.
The measure, which will make the state the center of stem cell research in the country, will establish an institute for regenerative medicine and raise close to $300 million a year for the next decade through bond sales, according to the Nov. 4 New York Times.
Backers of the controversial initiative say it will lead to the growth of a new bioscience industry in the state.
The New York Times is online.
Study questions value of ACE inhibitors for heart disease
Study results released last week found that ACE inhibitors provide little protection against fatal heart attacks and strokes in patients with stable coronary artery disease.
The study tested the theory that adding ACE inhibitors to conventional therapy further protects against cardiovascular events in patients with stable coronary artery disease and normal or slightly reduced left ventricular function. In the trial, half of the more than 8,000 patients received 4 mg of trandolapril daily, while half received placebo. (Trandolapril was the only drug tested.) The study, which will appear in the Nov. 11 New England Journal of Medicine (NEJM), was released early online.
After a median of 4.8 years of follow-up, researchers found less than a 1% difference between the two groups in deaths from cardiovascular causes, myocardial infarction or coronary revascularization. They concluded that for patients receiving current standard therapy, there is no evidence that the addition of an ACE inhibitor provides increased protection.
An accompanying editorial noted that the failure of ACE inhibition to reduce deaths from heart events in this trial might be because patients-many of whom were on statins-already had a relatively low LDL cholesterol reading. ACE inhibitors may not reduce the rate of cardiovascular events if the LDL cholesterol concentration is sufficiently low.
According to the editorial, physicians should continue to use ACE inhibitors in higher-risk patients. Those include patients whose serum lipid concentrations are not adequately controlled or who have other uncontrolled cardiovascular risk factors, recurrent symptoms, and ongoing vascular inflammation or plaque instability.
The NEJM abstract is online.
ACP Journal Club: Studies look at exercise-based cardiac rehabilitation and exercise training in heart failure patients
Two reviews stress that exercise training is not only safe for patients with heart problems, but it also reduces the risk of death, both overall and from cardiac-specific causes following myocardial infarction. (A similar but not significant trend was found among patients with congestive heart failure.) The reviews were excerpted in the November-December ACP Journal Club.
In one review, the authors found that exercise training in patients with congestive heart failure improved their peak rate of oxygen consumption and cardiac output, as well as efficiencies in oxygen consumption. Exercise training also decreased their rate-pressure product, without increasing adverse events.
The second review focused on rehabilitation through exercise following myocardial infarction. Authors found that patients gradually improved their capacity for exercise, thus lowering their risk of developing cardiac symptoms. Exercise also resulted in lower levels of aldosterone, angiotensin, natriuretic peptides and vasopressin.
In the exercise training review, duration of training in the trials ranged from 15 minutes three times a week to 100 minutes seven times a week, over eight weeks. No exercise-related deaths occurred in any trial, while 57 trials showed an average 17% increase in oxygen uptake.
In the second review, cardiac rehabilitation after myocardial infarction was associated with reductions in total cholesterol and triglyceride levels, systolic blood pressure and smoking.
The evidence suggests that heart failure patients benefit from exercise programs, the reviewer said. However, Medicare covers rehabilitation only for patients with documented diagnoses of acute myocardial infarction within the past year, bypass surgery or stable angina pectoris. The reviewer suggests that the policy should be revised.
Links to both ACP Journal Club articles are online.
ACP Regent warns of increased MRSA risk
With the country entering flu season with only half of its ordered flu vaccine supply, a College Regent is urging internists to be on the lookout for cases of community-acquired methicillin-resistant staphylococcus aureus (MRSA).
In an upcoming ACP Observer article, Merle A. Sande, MACP, ACP Regent and an infectious diseases specialist, warns that flu sufferers are especially susceptible to community-acquired MRSA, which can lead to necrotizing pneumonia if untreated. Dr. Sande is afraid that fewer flu vaccinations due to scarce vaccine could translate into a spike in the number of community-acquired MRSA cases this year.
Dr. Sande advises internists to keep abreast of local community-acquired MRSA cases and to look for signs when treating patients for the flu. In addition to the characteristic boils of staph infections, other symptoms can be mistaken for the flu itself, such as high fever and shaking chills.
Drugs that do not treat community-acquired MRSA infections include the penicillin derivatives such as nafcillin and methicillin, as well as the cephalosporins such as cefazolin, ceftriaxone and cefalexin.
Those that are active include vancomycin, linezolid and daptomycin. And unlike hospital-acquited MRSA, many community-acquired strains may also be inhibited by trimethoprim/sulfamethoxazole, the quinolones and clindamycin. Getting cultures with sensitivity testing is particularly important, Dr. Sande said.
More information about MRSA is online.
Intradermal flu shots may extend vaccine supply
Two new studies found that injecting influenza vaccine into the skin may help stretch limited supplies of flu vaccine.
The studies compared the effectiveness of standard intramuscular vaccine injections vs. smaller doses (20%-40% of the usual dose) delivered intradermally. Both studies found that small intradermal doses conferred similar antibody responses in adults up to age 60, although patients over 60 had a better response to intramuscular vaccine. The studies, which will appear in the Nov. 25 New England Journal of Medicine (NEJM), were released early online.
While findings suggest a potential solution to the current vaccine shortage, it is premature to start using intradermal injections, according to experts interviewed in the Nov. 4 New York Times. The studies were limited by their small size, with less than 340 participants, and the fact that researchers used blood tests instead of actual flu cases to measure immune response.
Results also indicate that smaller doses would be least effective in those at highest risk, including the elderly and those with chronic diseases, the New York Times reported. However, it is likely that some physicians who fail to secure an adequate vaccine supply may resort to using lower doses in some patients.
Links to the NEJM abstracts are online.
The New York Times is online.
In related news, a Dutch study found that seniors who receive annual flu shots reduce their risk of dying from the virus by 24% in any given year.
The study, which looked at more than 26,000 patients age 65 and over, found that getting vaccinated over several years was more effective than a one-time shot. Researchers found that a first vaccination reduced senior patients' risk of death by 10%, whereas revaccination reduced their risk by 24%. The study was published in the Nov. 2 Journal of the American Medical Association (JAMA).
Researchers said that revaccination gave the elderly even more protection during flu epidemics, when their mortality risk was reduced by 28%. The findings confirm many physicians' advice to seniors to get annual vaccinations.
The JAMA article is online.
Medicare to boost overall physician payments by 4% in 2005
Medicare last week issued its final payment rule for 2005, which includes a 1.5% increase for all services as part of the annual update and more coverage for preventive care.
Under the new rule, which takes effect Jan. 1, the CMS will cover an introductory physical for all new beneficiaries and screening for cardiovascular disease and diabetes, according to a Nov. 3 CMS news release. Physicians will be able to bill separately for electrocardiograms as well as for medically necessary office visits with patients' preventive physical exam.
Payments for vaccinations and other injections will be increased substantially-from $8 to $18 for a flu vaccination, for example. The new rule also adopts 18 new billing codes for drug administration and allows physicians to bill extra for infusing a second drug, for an overall 120% increase over 2003 payments for drug administration services.
The increase in payments for administration of infused drugs will help offset the fact that payment rates for most Part B drugs will decrease. That is because those rates will be set at 106% of the average sale price (ASP) based on quarterly data from manufacturers, as opposed to the previous method of paying 95% of the average wholesale price.
The Medicare demonstration program for cancer care (see below), which will add another 15% to oncologists' payments, will further offset payment reductions caused by the switch to 106% of ASP.
In addition, the CMS said it will offer 5% quarterly incentive bonuses to physicians who practice in underserved areas.
A list of the "scarcity areas" eligible to receive the 5% bonus is online.
The CMS news release is online.
CMS will launch cancer care demonstration project
Medicare last week announced plans to launch a one-year cancer care demonstration project in 2005. The project will be part of a new effort by the agency to tie physician payments to data collection efforts and patient enrollment in demonstration projects that examine the effectiveness of specific treatments.
The project will measure outcomes in three areas for patients undergoing chemotherapy: controlling pain, minimizing nausea and vomiting, and reducing fatigue, according to a Nov. 1 CMS fact sheet. The CMS will collect data from participating physicians and use those data to track improvements, such as fewer hospitalizations.
Any physician who cares for cancer patients and administers chemotherapy is automatically enrolled in the demonstration by using new billing G-codes listed on the agency's Web site. Three new codes must be entered per patient visit, which is defined as a day when chemotherapy is administered through infusion or push. Practices reporting data in all three areas will qualify for an additional $130 payment per visit.
The project design is part of a new Medicare initiative to evaluate treatments before the CMS decides to cover them, the Nov. 5 New York Times reported. The agency's goal is to evaluate how well treatments work, whether older drugs work as well as new ones and whether people of varying ages have different responses to different drugs.
The CMS fact sheet with the new billing codes is online.
The New York Times is online.
IOM warns about ongoing threats to rural health care
The Institute of Medicine (IOM) released a report last week, warning that rural health care providers and institutions could fail to benefit from quality improvement and performance measurement programs that are designed to boost health care quality.
In its "Quality Through Collaboration: The Future of Rural Health" report, the IOM pointed out that rural facilities still find it hard to attract health care providers and invest in quality improvement programs. That lack of resources will make it difficult for rural providers to create the information technology infrastructure needed to deliver more effective care to rural patients, the report said.
According to the Nov. 2 Modern Physician, the report made several recommendations, including calling on the CMS to fund a five-year pay-for-performance project for rural providers. The IOM also wants the Agency for Healthcare Research and Quality to analyze the impact of changes in Medicare and Medicaid funding, as well as of private insurance coverage, on the financial viability of rural health care programs.
Information about the IOM report is online.
Modern Physician is online.
College supports new WHO initiative on HIV/AIDS
ACP has endorsed a new World Health Organization (WHO) initiative that seeks to improve treatments for HIV/AIDS patients in developing countries. The proposal--which is called the "3 by 5" initiative--wants to provide 3 million infected patients worldwide with antiretroviral treatment by the end of 2005.
In a Nov. 2 letter, College President Charles K. Francis, FACP, applauded the WHO's focus on evidence-based interventions and its efforts to improve technical resources and expertise in countries affected by the HIV/AIDS epidemic.
According to a WHO press release, the initiative will work to expand the number of trained health care workers in developing countries; establish distribution systems for antiretroviral drugs; create financing systems so patients won't have to impoverish themselves to get treatment; and create adequate local infrastructures to dispense health information.
The letter is online.
The WHO press release is online.
College EVP taking part in roundtable on election results
John Tooker, FACP, MBA, the College's EVP/CEO, is taking part this week in a roundtable discussion on findings of a new consumer health care poll taken after last week's election.
The Nov. 10 Washington roundtable will also explore the post-election views of other health care stakeholders, including seniors, business leaders, and physicians. The forum is being sponsored by Blue Cross and Blue Shield Association (BCBSA) and Forbes magazine.
Other panelists joining Dr. Tooker include Mark McClellan, FACP, PhD, the CMS administrator; Scott Serota, BCBSA's president and CEO; and Steve Forbes, Forbes' editor in chief.
More information is online.
Wanted: internist to help brief Congress on language issues
The College is looking for an ACP member who is part of a solo or small group practice to help educate members of Congress about quality of care issues for patients with limited English proficiency. The Congressional briefing will take place in Washington on Dec. 9, and funding is available to pay travel expenses.
Speakers are encouraged to discuss the availability of language services for these patients, as well as funding and operational problems. The briefing is designed to provide background material to Congressional members and their staff about language access issues.
The College is part of a coalition that helped organize the briefing and is working to improve access to better quality language services in health care. The College recently endorsed a statement of principles produced by the coalition to improve access and funding.
Members interested in speaking at the briefing should contact Rachel Groman in ACP's Washington office at 202-261-4546 or at email@example.com.
The coalition statement of principles is online.
An article in the Nov. 2 ObserverWeekly reported that the CDC had created a permanent ethics panel to help the public health agency decide how to allocate flu vaccine during a shortage. According to a CDC spokesperson, that panel will not be permanent and will serve only in an advisory capacity, with no ability to make consensus decisions.
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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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