In the News for the Week of 7-20-04
Clinical news in the headlines
- Medicare moves to make obesity an illness
- Coalition designs roadmap for national technology network
Medical liability news
- Malpractice cap reduces awards by 30%
- New IOM committee to focus on performance measures
- ACP Services votes to establish a PAC
- New College service helps members select office software
- Register for Annual Session 2005 by July 31 and save $50
- ACP: Cigarette packs should carry stronger health warnings
Clinical news in the headlines
People at high risk for heart disease should consider taking higher doses of statins to achieve much lower levels of LDL cholesterol than previously recommended, a government advisory panel announced last week.
The NIH's National Cholesterol Education Program (NCEP) said that patients in the highest risk categories for heart disease should try to lower their LDL cholesterol levels to less than 70 mg per deciliter. While the new recommendations do not replace official NCEP guidelines published in 2001, they do advise physicians to consider a goal of 70 mg/dl as a "therapeutic option" based on evidence from recent clinical trials. The 2001 guidelines, by contrast, recommended reducing LDL in high-risk patients to less than 100 mg/dl.
The NCEP panel met to review five clinical trials published since 2001 that provide strong evidence for lowering LDL cholesterol below current targets, according to the July 13 Washington Post. In those trials, aggressive statin treatment proved particularly beneficial for people with one or more serious risk factors such as existing heart disease, diabetes, high blood pressure, smoking or obesity.
The NCEP paper, published in the July 13 Circulation, advised physicians to tailor the intensity of statin therapy to achieve a 30% to 40% LDL cholesterol reduction in patients at high or moderate heart disease risk. The panel also made a strong case for treating diabetics with statins even when their initial LDL cholesterol is less than 100 mg/dl. The panel also recommended therapy for those with a combination of diabetes and heart disease, regardless of their baseline LDL levels.
According to the new recommendations, anyone at moderately high risk for heart disease due to obesity or other lifestyle-related risks should try therapeutic lifestyle changes instead of or in combination with statin therapy. Physicians should then consider prescribing statins for these patients if their LDL is more than 130 mg/dl after lifestyle changes, with a goal of less than 100 mg/dl being a "therapeutic option."
The Circulation abstract is online.
The Washington Post is online.
The following articles appeared in this week's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online.
Guidelines for heart patients and air travel. After reviewing literature on heart patients traveling by airplane, authors discuss effects of air travel and security devices on pacemakers and implantable automatic defibrillators, preflight screening, and in-flight venous thrombosis and make recommendations on safe air travel after heart attacks and prevention of in-flight deep venous thrombosis. Authors also present a nine-item pretravel checklist for patients with cardiovascular disease. More.
Long-term antibiotic use doesn't ease Gulf War illnesses. A 12-month course of the broad-spectrum antibiotic doxycycline did not improve symptoms of Gulf War veterans' illnesses, a new study found. The researchers did the study because of speculation that infection with Mycoplasma caused Gulf War illness. More.
Does a living will affect chance of not dying in a hospital? A study of data on elderly patients who died in the United States between 1993 and 1995 found that 40% had living wills. People with living wills were more likely to die at home or in a nursing home than in a hospital. More.
CMS officials last week removed language from the Medicare coverage manual stating that obesity is not an illness. The policy change paves the way for Medicare to consider covering weight-loss treatments proven to be effective.
The change will likely lead to many applications from individuals, physicians and companies requesting coverage for various treatments under the Medicare program, according to the July 16 Washington Post. Uncovered therapies include bariatric surgery, diet programs, and behavioral and psychological counseling.
The decision is another step in the government's campaign to combat the rising number of obese Americans and may pressure private insurers to expand coverage for obesity treatments as well. According to the Washington Post, some health experts applauded the decision while others criticized it as "fixing" a problem instead of endorsing strategies to prevent it, such as promoting exercise in schools and restricting advertising of fatty foods that targets children.
The CMS is planning a fall meeting to review the evidence on the effectiveness of various obesity treatments, including bariatric surgery. New requests for coverage must be accompanied by published, clinical trial data that illustrate how a treatment improves health.
Details of that coverage process can be found on CMS' Web site.
The Washington Post is online.
A public-private health care coalition last week outlined preliminary recommendations for building an interoperable health information technology infrastructure that would include financial incentives for physician investment.
In its report, the group Connecting for Health recommended that physicians should receive financial incentives from a combination of government, health plans and self-insured employers.
While the group plans to announce further details later this summer, its preliminary report stated that primary care practices should receive $3 to $6 per patient visit or 50 cents to $1 per patient per month to support adoption of electronic medical record systems, according to the July 14 Modern Physician. The report focused on small to medium-sized practices, which have the lowest rate of information technology adoption.
The report further said that financial incentives for information technology must be "meaningful," interpreted as 5% to 10% of a physician's annual income, or $10,000 to $20,000. That translates into total incentives of about $7 billion per year for three years, or 1.2% of the amount spent on ambulatory care in 2003, Modern Physician said.
In addition to financial incentives, the report outlined two other broad categories for action. They included recommendations for a nonproprietary information network that would not use national health identification cards or a centralized database of records, and for a national educational campaign to address consumers' concerns about information technology. Later this week, the coalition will release an analysis of research on public attitudes toward personal health records.
Connecting for Health consists of more than 100 public and private health care organizations and receives funding from the Robert Wood Johnson Foundation. The College's Executive Vice President, John Tooker, FACP, sits on the steering group that drafted the report.
The Connecting for Health report is online.
Modern Physician is online.
In related news, ACP earlier this week released a legislative proposal designed to facilitate adoption of health care technology in small physician practices. The College is actively seeking Congressional sponsors to introduce a bill that incorporates ACP's proposal.
In a July 19 press release, the College pointed out that half of all practicing physicians in the country work in practices with six or fewer physicians. Such small practices, the release pointed out, often cannot afford the cost of electronic health record (EHR) systems, which average $30,000 per physician. While the College is working toward enhanced technology adoption by all physician practices, it is advocating for special attention for small practices through financial incentives and pilot programs to test standards.
In the release, ACP President Charles K. Francis, FACP, pointed out that the proposal includes provisions for tax credits, grant and loan programs, and reimbursement incentives. Current Medicare payment policies, the release noted, discourage physicians from acquiring and using information technology because those policies don't provide separate payments for e-mail consults or add-on payments for office visits supported by EHRs.
The College's press release is online.
Medical liability news
A new report has found that California's cap limiting medical liability awards for noneconomic damages at $250,000 has cut jury awards in the state by 30%.
The Rand Corporation study looked at more than 250 successful plaintiff cases in California between 1995 and 1999, according to a July 12 Rand press release. The study found that judges had to reduce pain and suffering amounts awarded by juries in 45% of cases by a median of $366,000, the July 13 Los Angeles Times reported. Patients with severe injuries such as brain damage or paralysis had awards reduced by more than $1 million each, while damages for infants were cut 71% of the time, often by amounts exceeding $2 million.
The study found that 55% of jury awards for noneconomic damages fell below the cap. According to the Los Angeles Times, critics of the law hold this up as evidence that capping noneconomic damages affects only the most severely injured patients and greatly diminishes their quality of life.
However, proponents of tort reform said the award reduction shows that the law is working and helping to keep insurance rates in check. While the Rand study did not address premium rate changes, data collected by a California insurance information network shows that malpractice rates have risen by 168% in California since 1975 when the cap was passed, compared with 420% in the rest of the country.
The study also found that the combination of state limits on both noneconomic awards and attorney's fees resulted in a 60% reduction in the amount collected by plaintiffs' attorneys. California's tort reform provisions are often held by tort reform proponents--including the College--as a model for federal and state tort reform efforts.
The Rand Corporation press release is online.
The Los Angeles Times is online.
A committee newly-appointed by the Institute of Medicine (IOM) will begin meeting next month to consider the future role of performance measures in quality improvement efforts.
The committee, which plans to issue a report within two years, will develop recommendations and establish criteria for selecting performance measures that will be linked to physician performance, particularly for services given to Medicare beneficiaries. According to the IOM Web site, the committee includes several ACP members, including Alan R. Nelson, MACP, Special Advisor to the College's Chief Executive Officer.
According to Dr. Nelson, the committee itself won't be developing performance measures but will be providing critical analyses of existing measures as well as an evidence base of the efficacy of measures in improving quality of care. Over the next two years, the IOM committee will also be taking testimony from various stakeholders, including physician groups, on how performance measures should be used for variable payments to physicians.
The IOM committee and its upcoming report were mandated by the Medicare reform bill passed last year.
More information is online.
The Board of Directors of ACP Services Inc. voted over the weekend to form a political action committee (PAC).
That PAC, which must be registered with the Federal Trade Commission within 10 days, will provide a way for internists to voluntarily contribute money to Congressional candidates who support the College's mission and goals, subject to federal guidelines on disclosure of contributions and dollar limits.
Because of the College's tax status as a charitable organization, ACP cannot establish a PAC. ACP Services, a separate association created in 1998 to provide advocacy and practice management services to members, enjoys a different tax status, allowing it to establish a PAC. Because ACP members are also members of ACP Services Inc., they will have the opportunity to contribute to the PAC on a purely voluntary basis. The PAC will not be accepting contributions until its Board decides on policies for candidate support.
In January, the ACP Board of Regents approved a request to ACP Services to form a PAC. After studying the request for six months, the ACP Services' Board of Directors decided that a PAC would help strengthen grassroots and lobbying efforts to improve health care and medical access for patients, according to ACP Services' President William E. Golden, FACP.
An ACP Services press release is online.
A fact sheet on PACs is online.
ACP's Practice Management Center (PMC) is now offering a new service to help College members select software for their electronic medical record (EMR), transcription, billing, and other office systems.
PMC has arranged with KLAS Enterprises LLC, a leading health information technology survey and evaluation firm, to give College members valuable software product evaluations and comparison data. In return for participating in a brief evaluation of their own practice's current software, College members can download an unlimited number of free KLAS Online summary reports on individual vendor products in various market categories.
For practices considering the purchase of a software system, PMC has also negotiated deep discounts for ACP members on subscriptions to KLAS' Platinum Service, which includes more extensive, updated comparison data on the top 20 products in each category surveyed, such as EMRs, billing and scheduling software, and dictation and transcription systems.
Platinum KLAS subscriptions also include a list of products given "Best in KLAS" awards and the ability to perform side-by-side comparisons of up to five selected products.
Subscribers also receive discounts on buying more extensive, in-depth product perception and evaluation reports, which include technical and market information about vendor products and the industry.
More information about the new service is online.
The College is offering two good reasons to register now for Annual Session 2005 in San Francisco: You'll save up to $50 in registration fees, and you'll be entered to win free airfare to the "City by the Bay" for yourself and a guest.
Both offers are in effect until July 31. Early registrants also get first choice of housing accommodations for Annual Session, which will be held next year from April 14-16.
Annual Session, internal medicine's premier educational and networking event, helps you keep abreast of the latest clinical information in internal medicine and find answers to common patient management problems.
The meeting offers more than 260 CME offerings in general internal medicine and internal medicine subspecialties, as well as hands-on clinical skills workshops, and a range of activities in physical examination and office-based procedures at ACP's Herbert S. Waxman Learning Center.
More information and a registration form are online.
The College is urging the Federal Trade Commission (FTC) to require more prominent addiction warnings on cigarette packages, in addition to the current health warnings.
In the July 14 letter to the FTC chair, College President Charles K. Francis, FACP, said the College supports requiring warning labels that cover at least half of the package surface.
Currently, package warnings--which are placed on the side of cigarette packs--take up only 20% of the package surface. In contrast, the letter said, Canada recently passed regulations requiring anti-smoking labels that take up 50% of the package surface and are placed prominently on a pack's front and back.
The letter noted that ACP supports "complete federal regulation over tobacco products," but said that requiring much more prominent health warnings was an inexpensive and effective first step in educating the public about the dangers of smoking. The letter pointed out that smoking is linked to at least one-third of all cancer-related deaths in the United States.
The letter 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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