In the News for the Week of 12-7-04
Clinical news in the headlines
- Highlights of the Dec. 7 Annals of Internal Medicine
Health care disparities
- Sharp racial disparities seen in HIV/AIDS diagnoses
- Equal effects of breast cancer drug found in whites, blacks
Business of medicine
- GAO: Oncologists in 2005 will see increased Medicare payments
- Progress slow on patient safety since IOM report
- College launches "Recruit-a-Colleague" program
- ACP creates new affiliate membership class for allied professionals
- ACP discussion group zeroes in on physician assistants
- College-endorsed sickle-cell disease bill becomes law
- ACP receives ACCME accreditation through 2010
Clinical news in the headlines
The following articles appear in the Dec. 7 issue of the Annals of Internal Medicine. Full text is available to College members and subscribers online.
Different COX-2s have different cardiovascular effects. A study being released early online found that patients taking the COX-2 inhibitor rofecoxib (Vioxx) had 2.72 higher odds for heart attack when compared to a group taking another COX-2 inhibitor, celecoxib (Celebrex). Rofecoxib was also associated with higher odds for heart attack compared with older non-selective non-aspirin non-steroidal anti-inflammatory drugs (NANSAIDs).
Researchers found that patients who used older over-the-counter NANSAIDs had a decreased risk for myocardial infarction compared to those who did not take NANSAIDS or who took one of the two COX-2 inhibitors. They also found no overall class effect of COX-2 inhibitors for heart attack. Findings support, the authors wrote, "the hypothesis that different COX-2 inhibitors differ in their cardiovascular effects."
The study and an accompanying editorial will appear in the Feb. 1, 2005, print edition of Annals. More…
Lack of sleep increases hunger, may promote weight gain. A study of 12 healthy young men in a sleep laboratory found that restricting sleep to four hours per day was associated with changes in levels of two hormones that regulate appetite. When sleep deprived, volunteers also reported feeling hungry, especially for calorie-dense foods with high carbohydrate content. Researchers say the study could provide a mechanism linking sleep loss to overeating and eventually to excess weight and obesity.
Authors of an accompanying editorial point out that the study does not find a cause-effect link between hormone levels and the feelings of hunger and actual eating. They also say that other factors, such as cortisol or orexin, might affect sleep and body weight regulation. More…
Health care disparities
According to HIV/AIDS diagnosis figures released last week by the CDC, the rate of diagnoses nationwide remained steady for 2000-2003. However, diagnoses continue to be disproportionately high for minority groups, particularly among African Americans.
Of the 125,800 new cases of HIV/AIDS diagnosed in 32 surveyed states from 2000-2003, 51% were African Americans, even though blacks make up only 13% of the surveyed population, a Dec. 1 CDC news release reported.
African American men, particularly homosexual men, had the highest rate of diagnosis in 2003, according to the release. The rate of HIV/AIDS diagnosis among African American women in 2003 was more than 18 times higher than among white women and five times higher than among Latina women.
According to the Dec. 2 Philadelphia Inquirer, the CDC estimates that up to 950,000 people are currently infected with the virus in the United States, but as many as 280,000 of them are unaware of it.
The CDC release is online.
The Philadelphia Inquirer is online.
A study published last week found that the breast cancer drug tamoxifen provides the same protection against metastasis in both white and African American women.
The study by scientists at the National Cancer Institute (NCI) analyzed data from 13 tamoxifen trials encompassing 20,878 women, a Dec. 2 NCI news release reported. While none of the trials alone included enough African American women to determine whether the drug performed differently based on race, scientists could assess its effect based on the combined total of 1,842 black women in the studies. Results were published in the Dec. 1 Journal of the National Cancer Institute (JNCI).
Researchers found that tamoxifen provided the same protection against contralateral breast cancer in blacks as it did in whites. While black women had a greater risk of blood clot-related events, researchers determined that the higher risk was not related to the effect of tamoxifen. Physicians were advised to assess the risks of the drug based on individual risk factors other than race.
Body mass index and age were identified as risk factors for contralateral breast cancer and blood clots, according to the NCI release. In addition, the study discovered a new association between the number of lymph nodes infiltrated by cancer cells and an increased risk of contralateral cancers.
The JNCI abstract is online.
The NCI news release is online.
Business of medicine
A government analysis released last week found that oncologists in 2005 will get 6% more in Medicare reimbursements for infused drugs than they will pay out in expenses. That 6% surplus follows a 2004 22% surplus between Medicare reimbursements and oncologists' drug infusion costs.
The report by the Government Accountability Office (GAO) based its estimate on 16 drugs that represented 75% of Medicare payments to oncologists for infused drugs in 2003, a Dec. 1 GAO letter to the House Committee on Energy and Commerce reported. At the same time, the GAO report claimed that payments for chemotherapy administration services in 2005 will increase by as much as 300% over 2003 levels.
The American Society of Clinical Oncologists (ASCO) took issue with the GAO's cost estimates, noting that its own survey of 140 practices found that drug-infusion payments will exceed costs by only 4% in 2005. ASCO also criticized the report for using CMS fee schedule rates to estimate practice expenses because the schedule under-represents chemotherapy administration costs that do not have a physician work component.
The GAO abstract with a link to the full report is online.
An expert commentary published last week found that five years after the Institute of Medicine issued its influential "To Err is Human" report on medical errors, the U.S. health care system hasn't made much progress towards improving safety.
Patient safety improvement efforts deserve an overall grade of C+, wrote Robert M. Wachter, FACP, chief of medical service at the University of California San Francisco Medical Center, who commented on developments in several areas related to patient safety including information technology and error-reporting systems. His commentary was published in the Nov. 30 Health Affairs.
Progress on patient safety has been hampered by the government's lack of financial investment in safety systems through the Agency for Healthcare Research and Quality, Dr. Wachter wrote, and by hospitals, which have largely failed to fund measures that would hire safety officers and train staff.
Improvements have been most impressive in the area of regulation, said Dr. Wachter, especially because of new JCAHO mandates requiring such protections as reading back patients' names and oral orders. He gave the lowest grade to the malpractice system, which he said demoralizes physicians and limits access. Institutions are doing a fair job of implementing information technology systems to combat medication errors, he wrote, but a poor job of processing error reports with an eye toward prevention.
Dr. Wachter, a noted leader of the hospitalist movement, also said the growing ranks of hospitalists represent a positive step toward improved safety. He noted, however, that office-based physicians often do not have the time to take on leadership roles for patient safety improvements and that smaller offices don't have the resources to invest in technology.
Health Affairs is online.
ACP members can now earn dues credits by recruiting non-member colleagues to become full ACP members.
Members will receive a $100 credit for referring one member and an additional $100 credit for two. If they recruit three or more colleagues, they will have their next year's dues payment waived. (Total credits cannot exceed member dues.)
The current "Recruit-a-Colleague" program runs until March 1, 2005. For every colleague they refer within this promotional period, members will receive a chance to win a trip to Annual Session 2006, including registration, airfare and four days of hotel accommodations.
To be considered a "recruited" member, your colleague must meet the following:
Be a nonmember (or former member) eligible for full ACP membership, so Associate or medical student members do not qualify.
Submit a membership application, along with his or her national annual dues payment, between now and March 1, 2005.
Include your name in the recruiter box at the top of the membership application.
Complete details of the program are online. You can use the same site to send a personalized recruitment e-mail to a colleague, or to download and print a membership application to personally deliver.
Membership inquiry kits are also available from ACP Customer Service at 800-523-1546, ext. 2600 (9 a.m.-5 p.m. ET).
For the first time, ACP has established a new class of membership that will be offered to certain non-physician health care professionals.
An invitation to become an ACP Affiliate has gone out to fellow members of the American Academy of Physician Assistants (AAPA), the only national organization that represents physician assistants in all medical and surgical specialties.
The creation of the new affiliate class was approved by the Board of Regents at its meeting in July. Having physician assistants as affiliate College members "is a milestone," said ACP Executive Vice President and Chief Executive Officer John Tooker, FACP, MBA, in a College press release. It is the first time in ACP's 89-year history that the College is offering membership to non-physicians.
The new ACP Affiliate members will have online access to Annals of Internal Medicine, as well as to ACP Journal Club. They also will have access to PIER (Physicians' Information and Education Resource), the College's point-of-care decision support tool.
Other benefits of affiliate membership will include access to ACP Online, as well as to ACP's Practice Management Center; discounts on College programs, publications and services; and continuing medical education programs at member prices.
More information about the new membership class is online.
Internists who want to hire a physician assistant or who have questions about how midlevel providers can make their practice more productive are invited to join this month's online Small Practice Management Discussion Group.
This month's topic, "10 Ways a PA Can Help Your Practice," is being moderated by Steve Crane, PhD, MPH, president and chief executive officer of the American Academy of Physician Assistants. The discussion group is sponsored by ACP's Practice Management Center.
The online discussion will center on how the use of physician assistants can boost productivity in small practices, as well as improve the quality of patient care, patient and physician satisfaction, and practice flexibility.
Targeted to College members in practices with between one and five physicians, the small practice newsgroup features a new topic each month, allowing participants to exchange information about what works in the small-practice setting.
You can join Dr. Crane and other discussion group participants online.
An ACP-endorsed bill to expand treatment and services for patients with sickle-cell disease, the blood disorder that primarily affects African Americans, has been signed into law.
The Sickle Cell Treatment Act (S.874/HR 1736), which was passed by Congress and signed into law earlier this fall, will increase funding for treatment and research, expand educational efforts and provide more patient services. According to a news release from the Sickle Cell Information Center, the law also earmarks $200,000 for grants to establish a demonstration project and a national coordinating center for research on prevention and treatment.
Other provisions include matching federal funds for state Medicaid departments to help cover doctor visits and lab services for sickle cell patients.
The sponsors of the original bills included Sens. Chuck Shumer (D-N.Y.) and Jim Talent (R-Mo.) and Reps. Richard Burr (R-N.C.) and Danny Davis (D-Ill.).
The Sickle Cell Information Center's news release is online.
ACP was recently awarded accreditation for six years as a provider of continuing medical education by the Accreditation Council for Continuing Medical Education (ACCME).
ACCME accreditation works to assure both physicians and the public that CME activities provided by accredited organizations meet high ACCME standards.
Those standards have been adopted by the seven organizations that sponsor the ACCME, which include the American Board of Medical Specialties, the American Hospital Association, the AMA, the Association for Hospital Medical Education, the Association of American Medical Colleges, the Council of Medical Specialty Societies and the Federation of State Medical Boards.
More information is online.
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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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