In the News for the Week of 9-21-04
The business of medicine
- CMS will pay for some PET scans for patients with dementia
Clinical news in the headlines
- FDA links antidepressant treatment to teen suicides
- Highlights of the Sept. 21 Annals of Internal Medicine
- Study: Survival rate is higher when HAART given earlier
- Some chronically ill patients stop meds without telling physicians
- CMS still seeking patients for drug demo project
- Medicare Web site posts drug price comparisons
- College co-sponsors health information technology summit
- Wanted: abstracts from ACP Associates for Annual Session
The business of medicine
The Centers for Medicare and Medicaid Services (CMS) last week announced that it will start covering PET scans for some patients suspected of having Alzheimer's disease. However, the CMS will cover PET scans only for patients who have atypical Alzheimer's symptoms and who may have one of several fronto-temporal dementia diseases, including Pick's disease.
The CMS announced that this specialized scanning is "reasonable and necessary" for patients who have displayed mental deterioration for at least six months, according to the Sept. 17 Washington Post. The agency added, however, that medical evidence does not justify scanning those who have only early dementia. The CMS had no immediate estimates regarding the numbers of those eligible or the tests' annual costs.
In public comments about the CMS' ruling, several physicians opposed covering PET scans to help diagnose fronto-temporal dementia diseases, concerned that the scans may be marketed as a diagnostic tool for Alzheimer's patients, the Washington Post reported.
To address those concerns, the CMS said it would cover PET scans only for patients with symptoms—such as the lack of social inhibitions and language difficulties—that were more apparent than memory loss. Patients also have to have undergone a complete physical as well as two mental status tests within six months, as well as standard testing for dementia.
The Washington Post is online.
Clinical news in the headlines
The FDA last week acknowledged for the first time that antidepressants are linked to a slight risk of suicidal behavior in children and teens.
The FDA's statement came one year after the agency's own drug-safety analyst first suggested that link, according to the Sept. 14 New York Times. FDA officials suppressed those findings and hired outside researchers to analyze data from clinical trials. Those researchers reached similar conclusions.
Some of the data were from studies that weren't published because of negative findings. A group of medical journal editors has since announced that they will not publish study findings unless trials are first registered in a public registry.
Officials noted that the risk of suicide is small, with 2 or 3 out of every 100 children and teens given the drugs becoming suicidal, and that no children in trials studied actually committed suicide. Almost 11 million children and teens were prescribed antidepressants in 2002, the New York Times reported. Suicide is the third leading cause of death among teenagers.
Why taking antidepressants may lead to suicidality is, the New York Times reported, "the subject of fierce debate." Some experts theorize that as patients' depression improves with treatment, they have more energy to act on depressive thoughts.
According to a Sept. 16 FDA press release, the agency's advisory committee has reached a split decision on whether to mandate black-box warnings for antidepressant labeling. At press time, it was unclear whether the FDA would move to require those warnings.
The New York Times is online.
The FDA press release is online.
The following articles appeared in this week's Annals of Internal Medicine. Full text is available to College members and subscribers online.
Chronically elevated blood sugar levels associated with heart disease. Two studies find that high levels of hemoglobin A1c are an independent risk factor for cardiovascular events. A meta-analysis of previous studies on glycosylated hemoglobin, diabetes and cardiovascular disease found that in people with type 2 diabetes, a one-percentage point absolute increase in glycosylated hemoglobin was associated with an 18% increase in cardiovascular disease risk and a 28% increased risk for peripheral vascular disease.
And a six-year prospective study of more than 10,000 patients found a 21% increase in cardiovascular events for every one-percentage point increase in hemoglobin A1c above 5%. More...
New hospital forms helped improve heart outcomes after discharge. Researchers found that the use of a new discharge form that included appropriate prescriptions and aftercare instructions for heart patients helped improve outcomes after discharge.
The form included prescriptions for beta-blockers, statins, ACE inhibitors and warfarin. Researchers found that fewer patients died after discharge or had to come back to the hospital within a year for heart problems. More...
A new study has found that HIV patients can avoid developing AIDS and live longer if combination drug treatments are started sooner than current guidelines recommend.
Researchers found that survival rates among HIV-positive injection drug users improved by starting highly active antiretroviral therapy (HAART) when patients' CD4 cell counts exceeded 350/ul. Current International AIDS Society guidelines recommend initiating HAART when CD4 cell counts fall below 200/ul. The study was published in the Sept. 15 Journal of Infectious Diseases.
The study was conducted by researchers from the New York Academy of Medicine and the Johns Hopkins University Bloomberg School of Public Health. According to a Sept. 13 New York Academy of Medicine press release, findings suggest that physicians should initiate HAART therapy earlier in HIV patients, when they are healthier.
The Journal of Infectious Diseases abstract is online.
The New York Academy of Medicine press release is online.
A new study released last week of chronically ill patients found that more than 16% of them delayed or stopped taking medications because of high drug costs. The study also found that two-thirds of those patients didn't tell their physicians about their underuse of prescription medications.
The study surveyed more than 4,000 adults age 50 and older who were taking medications for diabetes, depression, heart problems or high cholesterol. Reasons cited for not telling physicians about cost concerns were embarrassment and patients' belief that physicians could do nothing to help. The study was funded by the Agency for Healthcare Research and Quality (AHRQ) and was published in the Sept. 13 Archives of Internal Medicine.
Researchers found that when patients did approach doctors for help, most were given free drug samples or prescriptions for lower-priced or generic alternative drugs, according to a Sept. 13 AHRQ press release. However, the study found that only one in three patients who discussed cost problems with their physicians were given information about financial assistance programs sponsored by drug companies.
Researchers urged physicians to ask patients about their ability to pay for prescriptions and provide concrete information on ways to reduce drug costs.
The Archives of Internal Medicine abstract is online.
An AHRQ press release is online.
Only 7,000 Medicare beneficiaries have signed up to participate in a federal drug demonstration project that would help cover cancer medications and other costly drugs before the Medicare drug benefit takes effect in 2006.
The CMS announced this summer that a lottery would be held to fill some 50,000 slots in the program. The idea of a lottery may have discouraged some potential applicants, as perhaps did a complicated application process.
The program covers oral cancer medicines as well as self-injectable drugs for multiple sclerosis, rheumatoid arthritis and other illnesses. Medicare is no longer planning a lottery and will continue to accept applications beyond the previously announced deadline of Sept. 30.
Information about enrolling in the Replacement Drug Demonstration is online.
The Centers for Medicare and Medicaid Services last week began posting price comparisons of frequently prescribed brand-name drugs on its Web site. The posting is designed to help patients and physicians find lower-cost drugs.
The comparisons include prices for drugs used to treat high blood pressure, high cholesterol, arthritis, allergies and other conditions, according to the Sept. 16 New York Times. A total of 52 products are included, which together account for about 25% of all drug spending for Medicare patients.
The site does not include information comparing the effectiveness of different drugs to treat the same disease. Drug company representatives quoted in the New York Times expressed concern that the comparisons may lead some patients to assume that drugs in the same category are interchangeable, when in fact they may have very different effects.
Medicare's Quick Search for price comparisons is online.
The New York Times is online.
ACP is co-sponsoring a health information technology summit with practical sessions and policy presentations designed to help with the "how to" of using information technology to improve health care. The event is being organized by the eHealth Initiative and will be held Oct. 20-23 in Washington.
Summit attendees will network with more than 1,000 government and private sector health care leaders and information technology experts. The summit will feature cutting-edge information on Congressional, administration, private sector and innovative global initiatives related to information technology, including financial incentive programs and community-based collaboratives.
Sessions will be organized into tracks tailored to specific groups, including clinicians, hospitals and other health care providers, and health plans. Keynote speakers include David M. Brailer, MD, the administration's health information technology coordinator, and John Tooker, FACP, the College's Chief Executive Officer.
ACP members are eligible to receive a special discounted rate of $995 through Oct. 1, and $1,195 thereafter ($200 off the regular rate). To take advantage of this special discount, enter the discount code "ACP" when you register online.
The College is inviting all Associate members to submit abstracts for the research and clinical vignette poster competitions at the 2005 Annual Session. Residents and fellows are asked to submit abstracts of research findings, community service projects or interesting case studies.
Associates can submit up to two clinical vignettes and two research abstracts. There will be 20 winners, 10 in clinical and 10 in research. Last year's competition generated just under 1,600 abstracts.
All abstract submissions must be postmarked by Oct. 1, and winners will be notified by Feb. 1, 2005. Annual Session 2005 will be held in San Francisco April 14-16.
More information and a downloadable submission form are online.
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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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