In the News for the Week of 8-31-04
- Census Bureau: Number of uninsured is on the rise
- Arthritis drug maker warns of potentially fatal side effects
- DEA issues new guidelines on prescribing pain medications
Clinical news in the headlines
- Hospitals gain, but physicians still waiting for benefits of Texas tort reform
- CMS clarifies "incident to" billing rules
Education and prevention tools
- Free physician toolkit focuses on preventing falls
- Course designed to help internists diagnose problem drinking
- New College brochures can educate patients on heartburn and cholesterol
The U.S. Census Bureau last week reported that the number of uninsured Americans jumped in 2003 to a record 45 million. The figure represents an increase of 1.4 million over 2002.
The ranks of the uninsured included 20.6 million workers who have full-time jobs, according to the Aug. 27 New York Times-an additional 1.6 million more than in the previous two years. Analysts claimed the rise underscored a trend among employers to curtail health care benefits to cut costs.
The New York Times also reported that a report released last week by a benefits consulting firm noted that some employers are facing health care cost increases in 2005 of 13%. To counter those increases, more employers may cut health care benefits or pass coverage costs along to employers.
The Census Bureau reported that among ethnic groups, 32.7% of Hispanics were uninsured in 2003, 18.7% of Asian-Americans and 18.5% of blacks. The rate among non-Hispanic whites was 11.1%.
The New York Times is online.
The maker of the drug infliximab (Remicade) recently warned physicians that the drug may lead to sometimes fatal blood and central nervous system disorders. The drug is used to treat patients with rheumatoid arthritis and Crohn's disease.
In a letter sent to physicians Aug. 11, Centocor Inc. warned that some patients taking the drug had experienced leukopenia, neutropenia, thrombocytopenia and pancytopenia-some with fatal outcomes.
The letter made it clear that a causal relationship between infliximab and the disorders has not been established, and spokespersons for both Centocor and the FDA said the benefits of taking infliximab still outweigh the risks.
The letter stated, however, that physicians should consider stopping the drug in patients who develop significant hematological abnormalities. The letter also said that physicians should be on the alert for adverse reactions, such as persistent fever, especially in patients with histories of blood abnormalities.
According to the Aug. 25 Philadelphia Inquirer, the FDA has received 580 adverse reaction reports about patients taking infliximab, with 12 deaths reported worldwide. More than 500,000 patients have been treated with the drug in the past 10 years.
Centocor has previously revised its labeling of infliximab to warn that congestive heart failure patients may see their condition worsen on the drug, and that the drug could increase the risk of tuberculosis.
Physicians and patients who have questions about the drug can call the company at 800-457-6399.
Centocor's letter to the FDA is online.
The Philadelphia Inquirer is online.
The government has issued new guidelines on prescribing opioids, reassuring physicians that they can legitimately prescribe the medications for pain without running afoul of federal regulations.
The guidelines, written by U.S. Drug Enforcement Agency officials and a panel of national pain specialists, address a host of frequently asked questions on pain assessment, the appropriate use of opioids, risks of abuse and regulatory considerations.
The guidelines advise physicians on proper documentation, such as keeping detailed records of initial evaluations and follow-up visits; getting a complete treatment history; and regularly assessing a patient's pain intensity, side effects and drug use behaviors. The DEA also provides tips on how to spot "doctor shoppers," drug abusers who see multiple doctors to try and dupe them into supplying drugs for illicit uses.
The guidelines also maintain that opioids are safe and that physicians don't run any risk of being investigated or charged for appropriate prescribing. The document stresses, for instance, that physicians will not be arrested or indicted unless it can be proven that they have knowingly distributed pain medications outside the scope of legitimate practice.
The DEA's "Prescription Pain Medications: FAQs and Answers for Health Care Professionals and Law Enforcement Personnel" is online.
Clinical news in the headlines
A recent study of depressed patients found that their recovery rates improved when patients engaged in a series of telephone counseling sessions after starting drug therapy.
In the 18-month study, 600 adult patients beginning antidepressant therapy were randomly assigned to one of three treatment regimens: Usual primary care; usual care plus at least three outreach calls; and usual care plus eight telephone counseling sessions, which each lasted between 30 and 40 minutes.
Researchers found that 80% of patients being counseled over the phone showed significant improvement compared to only 55% of those given prescribed antidepressants without any outreach or counseling telephone calls. Results of the study appear in the Aug. 25 Journal of the American Medical Association (JAMA).
Researchers also noted that phone sessions were easier to schedule than office visits, cost less and reached patients in remote areas where therapists are often scarce. As a result, they found that patient participation was much higher for telephone counseling than for traditional in-person therapy.
While phone calls from nurses or clinicians have proven effective in helping people quit smoking or stay on medications, the JAMA study is the first to test standard cognitive behavior therapy by phone for depressed patients, according to the Aug. 25 New York Times. Researchers noted that 40% of patients who begin taking antidepressants quit taking them within a month.
The JAMA abstract is online.
The New York Times is online.
Two new studies comparing traditional with virtual colonoscopy suggest that virtual colonoscopy may be an effective tool for detecting colorectal cancer. The studies conclude, however, that it is too early to substitute virtual colonoscopy for more conventional screening methods.
One study, abstracted in the July-August ACP Journal Club, compared the use of virtual colonoscopy with optical colonoscopy (OC) in just over 1,200 patients at average risk for colorectal cancer. It concluded that the virtual method was sensitive and specific for detecting colorectal polyps and compared favorably with optical colonoscopy.
A second study included just over 600 patients presenting for colonoscopy. It found that virtual colonoscopy was inferior in detecting colorectal neoplasia and that the technology should not be considered for widespread clinical application.
The discrepancy between the two studies can be accounted for by their different characteristics. Whereas the first study was done under ideal clinical conditions, the second took place in more ordinary settings where patients would normally be tested.
The positive results for virtual colonoscopy in the first study were influenced by the use of specially trained radiologists, "electronic cleansing" of instruments (computer-based removal of residual fluid) and a three-dimensional detection technique-features not generally available under normal testing conditions.
The second study, on the other hand, is more indicative of virtual colonoscopy's actual effectiveness in a typical screening environment.
While some in the medical community are ready to accept virtual colonoscopy as a standard screening technique, there are no studies on whether it prevents deaths from colorectal cancer, and it is not yet recommended in guidelines.
ACP Journal Club is online.
Texas physicians' liability insurance premiums have not dropped despite last year's passage of state legislation to cap noneconomic damages in medical malpractice cases.
However, the caps have led to fewer lawsuits and lower premiums for hospitals in the state, according to the Aug. 23 Modern Physician. Hospitals responding to a Texas Hospital Association survey said their premiums in 2004 had dropped by an average of 8% and their number of lawsuits had been reduced by 70% since the law was passed.
Texas legislators last year voted for a $250,000 cap on most malpractice awards for pain and suffering. Soon after, voters approved a constitutional amendment giving the legislature power to set the caps, which went into effect Sept. 1, 2003.
While many doctors haven't yet realized savings, some of the state's large hospital systems, particularly those that self-insure for the first $10 million or more in losses, are passing along savings to the hospitals and physicians in their networks. One of the largest systems said it is reducing liability insurance premiums for its hospitals and surgery centers in Texas by 20%.
Modern Physician is online.
The CMS has issued a clarification for physicians on when and how to bill for "incident to" services.
"Incident to" services, billed as Part B services, are services provided as part of a patient's normal course of treatment either in the physician's office or patient's home.
These services can be billed as if the physician personally provided them, as long as the physician personally performed an initial service, provided direct supervision—in the same office suite, but not necessarily in the same exam room—and remained actively involved in the patient's treatment. For example, "incident to" services provided in the office must be provided by someone under the direct supervision of the physician and the physician must be on-hand to provide assistance if needed.
Examples of "incident to" services include cardiac rehabilitation and providing non-self-administrable drugs and other biologicals. The processes for billing differ according to where the care is provided.
Education and prevention tools
The Veterans Administration is now making an online falls prevention "toolkit" available for free to physicians.
The downloadable kit provides information on designing a falls prevention and management program, as well as effective interventions for high-risk patients; implementing hip protectors; and educating patients on injury prevention. The kit is available in MS Word and PDF formats and includes posters, fliers and other educational materials to help physicians design a complete fall-prevention program.
Data show that falls are the leading cause of injury among patients age 65 or older, with falls causing more than 85% of fractures in older patients. The kit is being offered by the Veterans Administration National Center for Patient Safety.
It can be downloaded from the center's Web site.
The College has joined with the Boston University School of Medicine to offer an Alcohol Clinical Training (ACT) course immediately prior to next year's Annual Session in San Francisco.
The ACT course, slated for April 13, 2005, is a "train the trainers" session designed for internists who teach medical students, residents and other health providers. The course will demonstrate a new Web-based alcohol screening and brief intervention curriculum aimed at helping physicians recognize and treat patients with alcohol problems.
The course will use slides, case-based videos and skills practice, with an emphasis on cross-cultural communication in the primary care setting. Scholarships and CME credits are provided.
The deadline to register for the afternoon course is Nov. 19. ACP's Annual Session 2005 is being held April 14-16.
More information is online.
ACP members can now order the two newest brochures in ACP's popular "Special Report" series of free patient education titles.
"Managing Your Cholesterol," developed in cooperation with the American Heart Association, educates patients about cholesterol, details high-cholesterol risk factors, and gives suggestions for controlling high cholesterol with diet and medications.
"Understanding and Treating Heartburn" helps patients understand the heartburn symptoms, common food triggers, and the difference between episodic heartburn, frequent heartburn, and heart attack. Readers also learn about treatment options, from diet and lifestyle changes to medication.
All the ACP Special Reports are available for free download online.
ACP members can also order free packs of 100 brochures.
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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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