In the News for the Week of 3-30-04
- CDC announces voluntary recall of nasal spray
The business of medicine
- Corporate coalition launches physician, hospital report card program
Clinical news in the headlines
- Quick antibiotic treatment may improve survival for older patients with pneumonia
- Therapy can improve somatization, but patients resist
- Highlights of ACP Journal Club
- Generic painkiller approval may help pain management, while raising abuse concerns
- Quick saliva test for HIV may boost screening
- Medicare trustees deliver bleak prognosis for program
- College endorses national electronic infrastructure conference
- Geriatric care: College members join 'train-the-trainer' project
- College sends recommendations to Congress on expanding coverage
The CDC announced last week that it had been notified of a voluntary recall of an over-the-counter nasal spray, due to potential bacterial contamination.
The product is a oxymetazoline HCI 0.05% nasal spray manufactured by Propharma Inc., and sold as "Major Twice-A-Day 12 Hour Nasal Spray." According to a March 24 CDC release, the spray may be contaminated with Burkholderia cepacia complex. The complex may cause severe infections in patients with underlying lung disease, especially cystic fibrosis.
The recall applies to lot no. K4496, which was released in November 2003 and expires October 2006. Cases of B. cepacia complex infection should be reported to local health departments or the CDC at 800-893-0485.
The CDC's release is online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a8.htm.
The business of medicine
A group of 28 major U.S. companies has launched an initiative to use insurance claims data to create report cards for physicians and hospitals. The companies' goal is to create a rating system to help employees choose the providers based on quality and cost.
The initiative, called Care Focused Purchasing, would use data from the medical care claims records of the group's 2 million employees and their dependants, the March 25 Modern Physician reported. The coalition already has data-sharing commitments from several insurers, including Humana and some Blue Cross/Blue Shield programs.
Critics of the initiative point out that medical claims data do not accurately reflect the actual quality of care, because they do not adjust for illness severity or take a patient's other chronic conditions into account.
However, a coalition spokesperson quoted in Modern Physician pointed out that claims data would be relied on for initial measurement until more sophisticated measures could be developed. Companies involved in the initiative include Sprint Corp., J.C. Penney Co., Pepsi, Xerox and Texas Instruments.
Modern Physician is online at http://www.modernphysician.com/news.cms?newsId=1955.
Clinical news in the headlines
Administering antibiotics within four hours of their arrival at a hospital may reduce lengths of stay and lead to fewer deaths among elderly patients with pneumonia, a new study has found.
The study, published in the March 22 Archives of Internal Medicine, used Medicare data from close to 14,000 pneumonia patients who had not received antibiotics before entering a hospital. Antibiotics were delivered within four hours to more than half of the patients at 71% of the hospitals.
Researchers found that early administration of the drugs was associated with a 15% reduction in mortality during hospitalization and for 30 days following admission. Almost 40% of the patients did not receive antibiotics within four hours, suggesting that there is an opportunity to improve survival rates, the researchers noted, and offer hospitals "substantial financial benefits."
Pneumonia is the second-leading reason for hospitalization among Medicare patients and the fifth-leading cause of death among Americans 65 or older, the authors noted. The results suggest that consideration should be given to revising current guidelines, which recommend giving antibiotics to pneumonia patients within eight hours of hospital arrival.
An Archives of Internal Medicine abstract is online at http://archinte.ama-assn.org/cgi/content/abstract/164/6/637.
A study released last week suggests that somatic patients can be effectively treated with psychotherapy. However, many patients resist getting therapy because they are convinced their problems are biologically based.
The study, which involved 102 patients who got psychotherapy and 85 who received routine medical care, found that 57% of patients who completed six therapy sessions showed improvement, compared with only 32% who got no therapy. The study appeared in the March 24 Journal of the American Medical Association (JAMA).
However, 25% of the patients randomized to the psychotherapy group stopped going to sessions prematurely and almost 14% failed to attend any sessions. Researchers speculated that these patients mistrusted psychotherapy because they believed their illnesses real.
The researchers noted that patients' somatic behaviors—such as a preoccupation with seeking health care information on the Internet—improved more than their somatic symptoms. This suggested, they noted, that reducing patients' fears and improving their quality of life, rather than eliminating symptoms, are realistic treatment goals.
To improve patients' compliance with psychotherapy, researchers suggested that therapy sessions be integrated into the primary care setting, and that patients should attend more initial as well as some booster sessions.
JAMA is online at http://jama.ama-assn.org/cgi/content/full/291/12/1464.
For more information, see "Strategies to treat unexplained symptoms" in the November 2003 ACP Observer at http://www.acponline.org/journals/news/nov03/somatization.htm.
Researchers found that patients with previous arterial or venous thrombosis, who also had the antiphospholipid antibody syndrome, had the same recurrence of thrombosis with high-intensity warfarin as with moderate-intensity warfarin regimens.
In a randomized study abstracted in the March/April ACP Journal Club, investigators found no difference in recurrent thrombosis between patients given high-intensity (INR 3.1 to 4.0) and moderate-intensity warfarin (INR 2.0 to 3.0). The study also found no difference between the high- and moderate-intensity groups as far as major bleeding.
Researchers concluded that for patients with previous arterial or venous thrombosis and antiphospholipid antibody syndrome, high-intensity warfarin was not better than moderate-intensity warfarin for preventing recurrent thrombosis.
More ACP Journal Club commentary is online at http://www.acpjc.org/Content/140/2/issue/ACPJC-2004-140-2-038.htm.
The FDA last week approved the first generic versions of the narcotic oxycodone, a move that promised cost-savings for patients with chronic or severe pain. However, the approval also raises fears about the growing potential for abuse of the painkiller.
According to the March 24 New York Times, time-release tablets of oxycodone (OxyContin) are effective for 12-hour pain relief. However, the drug, which has been implicated in more than 100 deaths, can be harmful or deadly if injected, snorted or chewed.
The FDA said that two drug companies could sell generic versions of oxycodone, but they must include potential abuse warnings in the drugs' labeling and take steps to educate doctors about minimizing illegal use. Purdue Pharma, maker of OxyContin, already takes similar steps. The New York Times reported that it is unclear when the generic versions of the drug would go on sale, because a patent dispute is still being decided in the courts.
The generic versions are expected to be significantly cheaper than OxyContin, which costs hundred of dollars a month. Earlier this month, the government announced that it is expanding its campaign to stop prescription drug abuse, including boosting efforts to monitor Internet drug sales and help states track patient use.
The New York Times in online at http://www.nytimes.com/aponline/health/AP-Generic-OxyContin.html.
The FDA announced last week that it had approved the first HIV screening test that relies on saliva and produces results in 20 minutes.
Along with providing more timely results, the new test—the OraQuick H.I.V.-1/2 Test—is much safer for providers testing patients, because it doesn't rely on sharps for blood tests.
Health officials said the new screening test could improve HIV screening percentages. Currently, the CDC estimates that 25% of patients who are HIV positive in the United States are not aware that they are infected, while that figure may approach 95% worldwide, according to the March 27 New York Times.
While the test can now be administered only in certified labs, the FDA is urging the test's manufacturer, OraSure, to apply for a waiver to make it possible for the test to be used in neighborhood clinics. According to the New York Times, the company is not applying to sell the test over the counter at this time, nor has the test been approved to screen donated blood.
The New York Times is online at http://www.nytimes.com/2004/03/27/health/27IMMU.html.
A report released last week predicted fiscal crisis for the Medicare program as costs are expected to soar due to expanded benefits for an aging population.
The report, issued by Medicare's board of trustees, said that rising health care costs and the effects of Medicare reform had led to more dismal financial projections for the Medicare program than in the past, according to the March 24 Washington Post.
Among the report's predictions: The Medicare program's hospital insurance trust fund will run out of money by 2019, seven years sooner than predicted last year.
The report also said that Medicare costs will grow faster than the overall economy, exceeding Social Security costs by 2024. Problems funding the program could be even worse than is reflected by current estimates, which are based on cutting average Medicare physician fees by about 5% a year between 2006 and 2012. Physicians, who are lobbying to prevent these cuts, saw a 1.5% increase in average fees this year and averted a scheduled 4.6% payment cut.
The new Medicare drug benefit recently approved by Congress adds to the financial problems, with total Medicare spending on the benefit expected to rise from $85 billion a year in 2006 to $161.8 billion in 2013.
The Washington Post is online at http://www.washingtonpost.com/wp-dyn/articles/A17672-2004Mar23.html.
ACP has given its formal endorsement to the second annual National Health Information Infrastructure (NHII) conference, to be held in Washington on July 20-23.
This year's conference, "NHII 04: Cornerstones for Electronic Healthcare," will bring together participants from all sectors interested in establishing a national health care electronic infrastructure, including physicians, payers, employers and patients. One of the goals of this year's conference is to map out an agenda for achieving a national information infrastructure in the United States within seven to 10 years.
The College has a strong interest in establishing an interoperable electronic information system that would allow all patient data to be digitally transmitted and shared in a uniformly accepted format. Such a system would optimize health care quality, reduce errors, increase physician productivity and reduce administrative costs and overhead.
More information on the conference is online at http://www.hsrnet.net/nhii/welcome.htm.
Eleven ACP members will participate in a physician leader training session that will focus on improving geriatric care. The session will take place at next month's Annual Session in New Orleans.
The program will develop, implement and evaluate CME models that have proven to be effective with community-based primary care physicians. It will follow an educational model of training leaders in small groups and teaching them techniques based on current CME and adult education research.
The project is being sponsored by the ACP's Education and Career Development Department and the Practicing Physician Education Project, which is funded by the Merck Institute of Aging and Health.
The program will use educational tool kits that address common geriatric problems such as falls, dementia and urinary incontinence. The kits provide an organized approach to common geriatric conditions, coordinated with screening and evaluation tools and educational handouts for patients and families.
The trained leaders can then lead similar training sessions at ACP Chapter meetings or with other local medical groups.
If you would like to participate in a future physician leader training session, contact Francine Martin at email@example.com.
In a statement sent earlier this month, the College outlined its proposal to extend health insurance coverage to all Americans by the end of the decade. The proposal was part of a statement for the record sent to the Health Subcommittee's Hearing on the Uninsured. The subcommittee is part of the House Ways and Means Committee.
First proposed in 2002, the College's plan, "Achieving Affordable Health Insurance Coverage for All Within Seven Years," calls on Congress to take the following steps, among others:
Enact legislation to expand Medicaid eligibility, convert the State Children's Health Insurance Program (SCHIP) to a federal-state entitlement program and create a tax credit/premium-subsidy program for people with incomes from 100% to 200% of the federal poverty level.
Expand the premium subsidy program to uninsured people with incomes above 200% of the federal poverty level and authorize the creation of purchasing groups.
Authorize states to opt out of the national framework for coverage, so states that meet guidelines would be able to use federal funding for state programs.
Develop a basic benefits package and recommend a mechanism to discourage people from voluntarily opting out of coverage.
The College's statement is online at http://www.acponline.org/hpp/way_means04.pdf.
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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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