In the News for the Week of 8-24-04
Clinical news in the headlines
The business of medicine
- Productivity jump outstrips pay raise for primary care
- Hospitalists reduce length of stay and long-term costs
- Moody's gives not-for-profit hospitals "negative outlook" rating
- GAO: Antikickback rules are discouraging physician use of IT
- College offers support in completing ABIM diabetes module
Clinical news in the headlines
A new study found that statins can dramatically reduce coronary heart disease events in diabetic patients who have normal levels of LDL cholesterol and no history of cardiovascular disease.
The research, which appeared in the Aug. 21 issue of The Lancet, found that giving those patients 10 mg of atorvastatin a day reduced their death rate by 27%, cut coronary heart disease events by 36%, reduced coronary revascularizations by 31% and lowered their rate of stroke by 48%.
The trial of nearly 3,000 patients was so effective that it was stopped two years ahead of schedule.
The study concludes that "no justification is available for having a particular threshold level of LDL cholesterol as the sole arbiter" of when type 2 diabetics should use statins. It says that the debate should now focus on whether any diabetic patients face a low enough risk of cardiovascular disease to withhold treatment.
An accompanying editorial, however, said it's premature to recommend the drugs for all diabetics. Cardiologists quoted in the Aug. 20 Washington Post countered that the editorial's conclusion is "completely off base" and that the study unequivocally demonstrates the benefits of statins in diabetic patients.
The Washington Post said that the American Diabetes Association will consider the study's results when it issues new guidelines on statins for diabetics early next year.
The Lancet abstract can be accessed online. Free registration is required.
The Washington Post is online.
ACP recently released a guideline advising physicians to treat any patient with coronary heart disease and type 2 diabetes with statins, regardless of their LDL concentration. The guideline is online.
A new study comparing the use of vasopressin with epinephrine for cardiac arrest is the latest to show that vasopressin does not improve survival. Findings suggest that vasopressin should not be the treatment of choice for resuscitating heart attack victims.
The large randomized controlled trial--involving almost 1,200 patients who suffered out-of-hospital cardiac arrest--found that the rates of survival to hospital discharge were not statistically different whether patients were given vasopressin or epinephrine. Two previous randomized trials reached similar conclusions.
The latest randomized trial, abstracted in the July-August ACP Journal Club, has some flaws. It used survival to hospital admission as the primary outcome rather than the more relevant measures of survival to discharge and neurological function. In addition, the researchers performed a subgroup analysis that found vasopressin to be superior to epinephrine in patients with asystole, contradicting the overall study results. This finding would need to be tested independently before accepting its conclusion.
The commentator for the article suggests that, with several studies showing disappointing results, the American Heart Association should consider changing its Advance Cardiac Life Support Guideline recommending vasopressin for cardiac arrest. Vasopressin should not be recommended until high-quality randomized trials show it to be at least on a par with epinephrine in producing clinically important outcomes.
ACP Journal Club is online.
The business of medicine
In 2003, productivity levels for primary care physicians increased more than their compensation for the third year in a row.
New data from the Medical Group Management Association (MGMA) show that median compensation for primary care physicians rose 2.4% last year. Productivity for those physicians, on the other hand, rose 6.1%.
A press release announcing the report says the data may indicate that primary care physicians are trying to maintain their current compensation by working harder.
Specialists reported a 7.95% increase in compensation for 2003. Noninvasive cardiologists saw their pay jump 13.59%, for instance, in part because of the competitive recruitment market.
The new report found that other specialties reporting significant gains in pay included gastroenterology, ophthalmology and urology.
A press release summarizing the new data is online.
New research found that while hospitalists reduce overall costs and length of stay when compared to other physicians, they actually spend more per day on patient care than their peers.
The study, which appeared in the August issue of the American Journal of Managed Care, found that hospitalists reduced patients' length of stay by one day, or 16%. Researchers also found that the hospitalists, who were working at the University of Iowa Hospitals and Clinics, saved roughly $900 per patient, or a 10% savings.
According to an Aug. 16 report in Modern Physician, the study estimated that two-thirds of hospitalists' cost savings come from reduced nursing costs, which are likely a product of shorter lengths of stay.
Researchers noted, however, that hospitalists actually spent $122 more per day than nonhospitalists. Researchers speculated this finding may indicate that hospitalists evaluate patients more intensely and more quickly than other physicians.
The study found that while costs were lower for lab services, costs for pharmacy and radiology services did not differ drastically.
Physicians in the nonhospitalist group included endocrinologists, nephrologists, rheumatologists, infectious disease specialists and general internists.
Researchers estimated that hospitalists saved the hospital 450 days of care during the year. They added that in the program's first year, it saved the hospital more than $370,000.
The study is online.
Faced with tightening reimbursements, growing expenses and sluggish growth in patient volume, the nation's not-for-profit hospitals have been given a "negative outlook" rating from a top financial institution.
Moody's Investors Service released its new rating of hospitals last week. According to the Aug. 19 Chicago Tribune, officials said that for the first time in three years, hospitals' median revenues failed to exceed their median expenses, underscoring the tenuous financial situation many facilities face.
Moody's based its report on an analysis of 344 of the nearly 600 not-for-profit health care systems that the company regularly rates.
Many hospitals say they are facing serious financial problems. They are battling stagnant rate increases from government and private insurers at the same time as their Medicaid populations are growing. Moody's officials noted that Medicaid represented a median of 9.6% of gross patient revenue in 2003, up from 9% in 2002.
The Chicago Tribune article is online.
A new report from the Government Accounting Office (GAO) warns legislators that physicians will be reluctant to embrace information technology because of concerns about federal laws regulating fraud and abuse, kickbacks, antitrust activity and tax penalties.
According to an Aug. 17 report by Modern Physician, GAO officials told a Senate committee that physicians aren't sure which types of relationships they can pursue with technology vendors without running afoul of fraud and abuse regulations.
The report pointed out that laws prohibiting self-referrals and kickbacks prohibit the establishment of certain arrangements between providers that could help encourage physicians to adopt information technology. The report concludes that as a result of these laws, physicians are reluctant to make significant investments in information technology.
In its response to the report, the HHS said that any guidelines for partnerships between technology vendors and physicians must be carefully crafted to avoid potentially abusive practices. The agency defined abusive practices as any arrangement that involved giving physicians free information technology or services.
An abstract of the report is online.
Modern Physician is online.
ACP has developed a collection of support materials to help members who are recertifying complete the American Board of Internal Medicine (ABIM) Practice Improvement Module on diabetes and improve quality of care in diabetes management.
The online support materials are divided into 17 chapters. The first four chapters include checklists, PowerPoint presentations, forms and Internet links designed to help physicians develop a chronic care model to improve quality measures in the office, design a patient registry, and manage and track patients with diabetes.
The remaining 13 chapters are organized along specific problems or desired outcomes common to patients with diabetes. (Selected topics are associated with evidence-based interventions that can improve patient outcomes.) The chapters include specific clinical guidance from PIER, the College's point-of-care clinical decision support system; tools to help you implement recommended changes; and patient education resources and a bibliography.
While the materials are designed to be used after you receive feedback from the ABIM on patient and office system audits, they can be used at any point in the recertification process. You can access the information 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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