In the News for the Week of 9-28-04
Clinical headlines in the news
- Medicare to mail drug discount cards to low-income patients
- More insured, chronically ill patients struggle with costs
- Some physicians asking patients for "malpractice surcharges"
- College co-sponsors National Depression Screening Day Oct. 7
- ACP creates site for recertification resources
- College urges House leaders to enact patient safety bill
- ACP to CMS: Strengthen QIOs' role in information technology
Clinical headlines in the news
Renal disease, even when it is mild, is a major predictor of death following a myocardial infarction, according to a study released last week.
The study looked at more than 14,500 patients with acute myocardial infarction complicated by heart failure. Patients were grouped according to their glomerular filtration rate (GFR), which is used to detect kidney damage.
Researchers found that the risk of death from cardiovascular causes increased progressively with declining GFRs. Below 81 ml per minute per 1.73m², each 10-unit decrease in the GFR was associated with a 10% increase in the relative risk of death or cardiovascular complications. The study appeared in the Sept. 23 New England Journal of Medicine (NEJM).
Researchers noted that the two-year mortality rate after myocardial infarction among patients with end-stage renal disease is approximately twice that of the general population. They claimed, however, that many physicians hesitate to give these patients medications—such as beta-blockers, ACE inhibitors and statins—to reduce cardiovascular risk.
While there is some concern that these drugs will reduce renal function, researchers said the medications should be considered for patients with chronic kidney disease, who have a higher risk of dying from cardiovascular events than from renal outcomes.
According to an accompanying editorial, the study reinforces the importance of detecting chronic kidney disease early. Early detection not only can slow disease progression through appropriate treatment, but also helps physicians identify heart disease risk factors.
The NEJM abstract is online.
A recent review found that individualized written action plans that allow asthma patients to take more control of managing their disease can improve outcomes.
The review of 26 randomized controlled trials comparing written action plans with usual care found that the most effective plans included peak expiratory flow monitoring; two-to-four action points when patients should intensify or prolong treatment or seek medical help; and the use of inhaled corticosteroids and oral corticosteroids. In the 17 trials that used individualized written action plans, reviewers found a risk reduction in both hospital admissions (34% versus 61%) and emergency department visits (13% versus 22%). The study was abstracted in the Sept.-Oct. ACP Journal Club.
Almost all of the written action plans included increasing the dose of inhaled corticosteroids, even though the current guideline for doubling inhaled corticosteroid doses in an exacerbation is not based on rigorous evidence. Reviewers noted that it is likely that poorly controlled asthma, which is distinct from an exacerbation, responds better to higher doses of inhaled corticosteroids.
Asthma patients have been slow to accept and use written action plans, reviewers said. This review and other evidence now suggest that written action plans are most effective if they include individualized instructions for increasing medication dosages during an exacerbation.
The ACP Journal Club abstract and commentary are online.
The federal government announced last week that it will mail Medicare drug discount cards to 1.8 million low-income beneficiaries who have not yet applied to any drug discount program.
Administration officials said the discount cards, which can save beneficiaries about 20% off the retail price of prescription medications, will reach beneficiaries over the next few weeks, according to the Sept. 23 New York Times. Patients can begin using them for discounts on Nov. 1.
Low-income beneficiaries with no other source of drug coverage can also qualify for up to $1,200 in federal credit toward prescription costs if they sign up for the credit by Dec. 31, the New York Times reported. To qualify, beneficiaries must call 1-800-MEDICARE and verify that they do not have other prescription drug coverage and that their income is less than $12,569 for an individual or $16,862 for a couple. Patients who don't apply by the Dec. 31 deadline will lose half the credit.
About 4.4 million people have signed up for the discount card program, many fewer than the 7.3 million beneficiaries the administration predicted when the program began earlier this year. Just over 1 million of those who have already signed up for the program qualify for the $1,200 credit.
The New York Times is online.
The number of insured patients with chronic conditions who spent more than 5% of their income on health care-related costs rose from 28% to 42% between 2001 and 2003, according to a study released last week.
The study detailed the growing problem of medical costs for adults with chronic conditions who have private health insurance. The study, with findings included in an issue brief from the Center for Studying Health System Change (HSC), credited those problems to rising deductibles and premiums as employers shift more coverage costs to employees.
About 57 million working-age Americans have chronic conditions, with more than 12 million of them living in families with medical bill problems in 2003, according to a Sept. 23 HSC news release. While access problems for insured patients were less severe than for the uninsured, 10% of those with chronic conditions who had private insurance in 2003 reported going without care, while 30% reported delaying care and 30% did not fill a prescription because of cost concerns.
The HSC news release and link to the issue brief are online.
A handful of physicians in some states are asking patients to help pay rising liability insurance premiums by voluntarily donating "malpractice surcharges" that range from $10 to $125.
The controversial strategy to help offset premium costs is a small but closely-watched trend, according to the Sept. 21 Washington Post. Physicians featured in the article in Maryland and Florida—both considered malpractice "crisis states" by the American Medical Association—have had considerable success appealing to patients for contributions.
According to those physicians, patients view a voluntary surcharge as just another access fee, akin to being charged for filling out forms or for phoning after hours, the Washington Post reported. Surcharge proponents say that asking for contributions will help engage the public in the debate over malpractice insurance. Critics warn, however, that the tactic may backfire as patients themselves face rising health care costs in the form of higher copays and insurance premiums.
In Maryland, the Washington Post reported, the insurer underwriting two-thirds of the malpractice policies in the state increased its rates 28% this year, while the state recently approved an average premium increase of 33% for 2005. A spokesperson from the Medical Group Management Association quoted in the article pointed out that mandating such a surcharge would violate Medicare rules, although asking for voluntary donations would not.
The Washington Post is online.
For more on access fees, see "Access fees have physicians moving cautiously" from the April ACP Observer online.
The College is partnering with a national nonprofit group to sponsor National Depression Screening Day on Thursday, Oct. 7. The event is designed to encourage communication and education about depression between primary care physicians and their patients.
ACP and the group Screening for Mental Health are offering College members free mental health screening toolkits to help them host local screening events. The toolkits include posters, brochures, fact sheets and videos, as well as information on holding community screenings.
The National Depression Screening Day, now in its 14th year, is the nation's largest community-based mental health screening program. The event provides in-person and online screening for four of the most frequently diagnosed mental disorders: depression, bipolar disorder, general anxiety disorder and post-traumatic stress disorder.
Information about the event is online.
To order a Screening for Mental Health toolkit, call 781-239-0071.
ACP members can also download the College's "Depression and Anxiety" patient education brochure online.
ACP Online now features a collection of information and resources on maintenance of certification.
The site provides links to ACP tools that can help physicians with the recertification process, as well as to information on the current process and its evolution and progress reports on discussions between the College and the American Board of Internal Medicine. Other College resources and a list of ACP Observer articles are also featured.
Members can access the information online.
The College is asking leaders of the House of Representatives to move this month to enact a bill that would establish a patient safety reporting system that would have confidentialty protections.
In a Sept. 20 letter, ACP joined more than 100 other medical and health care organizations in urging quick passage of the Patient Safety and Quality Improvement Act (H.R. 663). A Senate version of the bill passed in July, while the House passed a previous version in March 2003. The two bills must now be reconciled and a final version passed by both the House and the Senate before it can be signed into law.
If passed, the bill would establish patient safety organizations that would collect safety data submitted by health care providers. Those data would then be analyzed to help devise strategies for preventing similar errors. The measure would also include privacy protections and provide for civil fines for privacy violations. The bill would also provide confidentialty protections for both individuals and institutions reporting errors.
The letter was sent to the chair and the ranking member of the House Committee on Energy and Commerce.
The letter is online.
The College is asking the Centers for Medicare and Medicaid Services to ensure that quality improvement organizations—which have a good track record with ACP members—play an increasing central role in encouraging physicians to adopt health information technology.
In a Sept. 20 letter sent to the CMS' acting director, the College outlined a series of recommendations regarding QIOs and the need to move physician offices to using electronic medical records. Those recommendations included:
Allowing QIOs to work with subcontractors that have a thorough knowledge of local health care markets and support from the local physician community.
Not restricting QIOs to selecting subcontractors from a CMS-approved, nationally certified list.
Ensuring that QIOs or their subcontractors provide the initial stages of physician technical support and education to encourage information technology adoption.
Eliminating a proposal now being considered to mandate the use of outside contractors for all information technology adoption duties.
Offering physicians financial incentives to lower doctors' financial risk.
The letter is online.
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A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?
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