In the News for the Week of 4-27-04
Special Annual Session issue
- Nobel Laureate highlights progress in treating heart disease
- Regents tackle issues of performance measures, content integration and more
- Governors debate recertification strategy, electronic data collection
- New resource for online patient information
- Miss Annual Session? Order audio recordings
- Nature and nurture: twin culprits in obesity epidemic
- When should you refer asthma patients for an allergy consult?
During the Annual Session keynote speech, Nobel Laureate Joseph L. Goldstein, MACP, pointed out that in the 100 years since scientists first identified coronary artery disease, the condition has grown to account for one-third of all deaths in the Western world. Looking forward, the greatest advance of the next century could be to eliminate heart attacks completely, Dr. Goldstein said.
Dr. Goldstein, a key figure in the history of atherosclerosis research, discovered the genetic regulation of cholesterol. He and colleague Michael S. Brown, MACP, won the 1985 Nobel Prize in Physiology or Medicine for their groundbreaking insight into how cells extract cholesterol from the blood.
"Dr. Brown and I found the first molecular link in the story" of how cholesterol buildup leads to heart disease, Dr. Goldstein said. Since then, effective cholesterol-lowering drugs have had a dramatic impact on prolonging lives and preventing heart attacks.
"Very few chronic diseases have been subjected to such scrutiny," said Dr. Goldstein, "and seldom have the causes been demonstrated so convincingly."
Drs. Brown and Goldstein helped pinpoint the genetic cause of familial hypercholesterolemia (FH) by showing that receptors on the surface of cells control the uptake of LDL cholesterol.
Their initial research shed light on the genetic causes of atherosclerosis, but the medical community was still in doubt as to why people with the normal amount of LDL receptors also developed high cholesterol. Further research demonstrated that a high-fat diet can contribute to the problem.
High cholesterol is especially prevalent in North America and Europe, Dr. Goldstein said, where the average cholesterol level is much higher than in people in countries who have diets lower in cholesterol and saturated fat.
The combined result of research over the past 25 years—from the identification of plaque to genetic discoveries to the development of statins—strengthens the connection between high cholesterol and heart disease, said Dr. Goldstein.
"We now have four lines of evidence for the link between LDL and atherosclerosis," he said, "epidemiologic, therapeutic, genetic and experimental."
At a meeting held before Annual Session, the College's Board of Regents approved a policy paper on enhancing the quality of patient care by supporting the development of an interoperable exchange of electronic health care information.
The paper details the obstacles, such as cost and the lack of common medical terminology, to achieving that type of system. It also contains recommendations for overcoming those obstacles, including fostering collaboration between public and private sector groups, encouraging capital investment and promoting market-based solutions.
The Board also approved a position paper containing a broad set of recommendations on designing and implementing physician performance measures. Indicators that measure care processes—as opposed to outcomes—are more appropriate for assessing the performance of internists and other specialists who treat patients with chronic conditions. The paper is online at http://www.acponline.org/hpp/performance_measure.pdf.
The Regents also approved a recommendation to integrate all College content in an electronic information resource. The design of the integrated content would allow for incorporation of College materials in electronic health record systems and point-of-care decision-support technology.
The Board approved the College's second Clinical Efficacy Assessment Project (CEAP) guideline on the treatment and follow-up of chronic stable angina. The first guideline—on risk stratification and diagnosis of chronic stable angina—was approved by the Board in January. The guideline has been submitted for publication.
And the Regents accepted a statement of concern from the Council of Associates on the future of internal medicine training. The statement focuses on the "training-practice gap," which is the discrepancy between training and actual practice.
At their meeting last week, the Board of Governors approved a resolution recommending that the Regents set a deadline for meeting the goals set out in a resolution the Governors passed in 2002. That resolution recommended establishing multiple pathways to recertification, as well as testing that is relevant to different practice settings.
The resolution further recommended that the Regents assert a fundamental difference between initial certification, which confirms a strong knowledge base in internal medicine or a subspecialty, and maintenance of certification, which assesses a physician's continued professional growth.
The Governors also reaffirmed a previously approved resolution asking the Regents to participate in developing improved, interoperable computerized health records for all physicians. The resolution asks the Regents to represent internists' concerns with the development of those systems, including the effect on physician-patient interactions and the possible misuse of data by private insurers.
The Governors also approved a resolution asking the Regents to advocate for more portable medical liability insurance policies. The Governors also recommended that the Regents request a CPT code for validated screening of cognitive function, which would allow physicians to bill Medicare and other payers for screening services.
Another approved resolution asks the Regents to work with the Veterans Administration (VA) to create a process whereby VA patients could fill prescriptions written by non-VA primary care physicians at VA pharmacies.
The Governors' recommendations now go to the Regents for further action.
At last week's Annual Session, the ACP Foundation launched the Information Rx Project, a new program that helps physicians direct patients to MedlinePlus, a source for reliable, advertising-free health care information on the Internet.
The new service lets ACP members register to receive MedlinePlus prescription pads, office posters and bookmarks that they can give patients. At a press conference held at Annual Session, Jacqueline W. Fincher, FACP, a general internist from Thomson, Ga., who coordinated a pilot version of the program among members of the College's Georgia chapter, applauded the benefits of the program.
"It is so much better for physicians to give patients information," Dr. Fincher said, "than to have them use sites their friends stumble upon on the Internet." During the pilot program, she explained, 42% of physicians surveyed who had directed patients to the MedlinePlus site said the information improved their physician-patient relationship.
College members can register to receive free Information Rx materials at the ACP Foundation Web site at http://foundation.acponline.org/.
Audio recordings are now available of most pre-Session courses, updates and individual Annual Session presentations. The recordings come in a variety of formats including audiocassettes, audio CDs and a full set of MP3 audio CD-ROMs.
To order, call 888-649-1118 or go online at http://www.soundimages.net.
While obesity has become a major public health problem, the medical community is in a quandary over why some people gain weight—and whether doctors can do anything to help the most severely obese patients.
"Seventy-five percent of mature adults are overweight or obese," said Frank Svec, MD, PhD, professor of medicine at Louisiana State University Health Sciences Center, at an Annual Session presentation last week. "What happened to the other 25%? What keeps those people from becoming obese?"
Some audience members at the session credited genetics, while others said behavior—caloric intake or exercise—is more important. In fact, said Dr. Svec, an endocrinologist whose research focuses on the etiology of obesity, there's evidence on both sides.
And while Dr. Svec didn't profess to have a definitive answer, he leaned toward viewing social problems as the root cause of rising obesity. Children are exercising less and engaging in more passive activities, he said, such as watching television and playing video games. And overweight parents tend to perpetuate the problem by passing on bad eating habits and tolerating weight gain in their children.
Despite a plethora of low-carb diets, fat-burning drugs and surgical solutions that have emerged in recent years, physicians attending the session had few success stories. Gastric bypass surgery works with some severely obese patients, some audience members said, but no one reported much success with drugs.
Some said their patients had limited success with weight loss plans, such as the Weight Watchers program, or by using tactics such as keeping a journal and logging what they eat every day.
Dr. Svec offered these tips on ways to help patients:
Start with diet and exercise. Some patients will respond to diet and exercise advice and start to change their lifestyle.
Be honest. Tell patients their body mass index (BMI) and where they fall in that spectrum. With a BMI of 25 or more, a patient is considered overweight; 30 or more is considered obese.
Identify the risks. Tell patients that weight gain is associated with an increase in mortality and morbidity, as well as other problems such as high blood pressure and diabetes.
Start early. Start working with potentially obese patients when their BMI is between 25 and 30. Don't wait until they reach 35 or higher.
Don't ignore the small things. Keeping a journal of food eaten, monitoring portion size and staying abreast of weight gain can be effective strategies.
At an Annual Session presentation on referring patients, Phillip L. Lieberman, FACP, said that there are no set rules that tell you when to refer asthma patients to an allergist for a consult.
"When you look at allergic disease," said Dr. Lieberman, clinical professor of medicine and pediatrics at the University of Tennessee College of Medicine, "a consultation is often elective."
Dr. Lieberman was quick to add, however, that there are times when an allergy consult is essential to the proper care of asthma patients. He took a two-pronged approach, reviewing recent guidelines and dispensing tips from his own experience.
The well-known guidelines from the National Asthma Education and Prevention Program, for example, urge physicians to consider referring asthma patients who have persistent disease and need daily control. "In my opinion," he added, "these patients should have one shot at an allergy evaluation."
Recent recommendations from the CDC give even more detail about when to refer asthma patients. Those guidelines suggest that generalists should refer asthma patients with the following history:
- single, life-threatening episode;
- treatment goals not being met;
- atypical symptoms that make diagnosis unclear;
- history of episodes provoked by environmental factors;
- diagnosis of severe, persistent asthma;
- need for additional diagnostic testing;
- patient eligible for immunotherapy;
- patient requires continuous oral or high-dose inhaled steroids;
- patient has had more than two courses of oral corticosteroids in one year; and
- indication for anti-IgE therapy.
In terms of red flags that indicate a patient's asthma is not being adequately controlled, Dr. Lieberman listed the following signs that indicate an asthma patient could benefit from a consult:
- any hospitalization;
- more than one visit to the ER;
- more than two courses of oral corticosteroid per year; and
- persistent FEV1 less than 60%.
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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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