In the News for the Week of 1-11-05
Annual Session registration
- Register early for Annual Session and save up to $70
- Physicians should wait before volunteering overseas
Clinical news in the headlines
- Inflammation as important as cholesterol in heart disease
- Highlights of ACP Journal Club: Early invasive strategy vs. a conservative strategy in unstable angina and non-STEMI at advanced age
- CMS drug coverage: Panel recommends drugs to be covered in 2006
- Physicians get chance to rate their Medicare contractors
The business of medicine
- Survey company issues practice software ratings
- Medicare carrier warns about physician ID theft
- FDA approves first genetic test for drug interactions
- College: DEA sending mixed message on pain management
- ACP urges CMS to reassess E/M work relative value units
- Nominations sought for associate, student council members
Annual Session registration
Register for Annual Session 2005 in San Francisco by Feb. 11, and you'll save up to $70 on registration fees. You'll also get the best choice of hotels and reserved scientific sessions.
Annual Session, internal medicine's premier educational and networking event, helps you keep abreast of the latest clinical information and find answers to common patient management problems. It's also a great way to network with colleagues from around the world.
This year's meeting features over 260 CME offerings in general internal medicine and its subspecialties. Learning Center activities and hands-on clinical skills workshops allow you to learn valuable skills in physical examination, office-based procedures and more.
Annual Session 2005 will be held in San Francisco from April 14-16, and you must register by Feb. 11 to get the discounted rate. More information and a registration form are online.
Doctors eager to help tsunami victims in Asia and Africa are being told to wait until temporary hospitals and supply stations can be established.
Financial aid is the most vital immediate need, according to the Jan. 6 Philadelphia Inquirer. While a few agencies, including Doctors Without Borders, have sent medical help to stricken regions, most of the health care volunteers in those regions are coming from nearby countries.
Relief officials quoted in the article said the biggest danger now is the potential spread of dysentery and cholera. Many non-physicians who speak native languages and are being trained onsite are helping victims find safe water and learn basic preventive skills.
The infrastructure to house an influx of health care volunteers does not yet exist, the Philadelphia Inquirer reported. Temporary hospitals and supply streams are still being established, and volunteers would put an added strain on limited supplies of food, water and shelter. However, officials said that U.S. physician volunteers will be needed in about a month.
For those wanting to send financial aid, the Web site for the U.S. Agency for International Development (USAID)—the federal agency for international economic and humanitarian aid—lists charitable organizations that are helping in the disaster areas.
USAID has a list of relief agencies online.
An updated CDC site on tsunami-related health concerns is online.
The Philadelphia Inquirer is online.
Clinical news in the headlines
Two new studies suggest that statins' ability to reduce inflammation may be as important as lowering cholesterol to prevent heart disease.
Experts quoted in the Jan. 6 Washington Post said the studies represent the first "hard clinical evidence" that lowering inflammation reduces patients' risk of heart attacks and strokes. The results of the two studies—which both appear in the Jan. 6 New England Journal of Medicine (NEJM)—may also clear the way for researchers to develop new drugs that specifically target inflammation.
In the studies—one with 502 patients with heart disease, and another with 3,745 patients who'd experienced heart attacks or severe chest pain—a reduced rate of heart disease progression was associated with more intensive statin treatment and a greater reduction in C-reactive protein (CRP), a marker of inflammation. In both studies, patients received either moderate (40 mg) or intensive (80 mg) treatment with pravastatin or atorvastatin.
Some experts quoted in the Washington Post said the evidence is strong enough to suggest that doctors should begin testing patients' CRP blood levels to identify those who may have excessive inflammation, even if their cholesterol levels are low.
However, other experts advised caution, saying it is too early to start giving statins to people with normal cholesterol. An NEJM editorial noted that while the results are compelling, there is some concern that intensive statin use can impair lymphocyte function.
The Washington Post is online.
A recent analysis found that an early invasive treatment approach is more effective than a conservative one to prevent death or heart attack in elderly patients with unstable angina and non-ST-elevation myocardial infarction.
The study followed 2,220 patients with non-ST-elevation acute coronary syndromes for six months. Among patients 65 or older, an aggressive invasive strategy involving coronary angiography within 48 hours and revascularization when necessary resulted in fewer deaths and heart attacks than a conservative strategy (8.8% vs. 13.6%). (No such difference was seen in patients younger than 65.) The conservative strategy included medical treatment and an exercise test before discharge. The study was abstracted in the January-February ACP Journal Club.
Using data from the TACTICS-TIMI 18 trial, researchers found that despite the therapeutic benefit and cost-effectiveness of an invasive approach for the elderly, this strategy was used less frequently as patients got older. While this may be due to patients' greater risk of bleeding, the ACP Journal Club reviewer noted that steps can be taken to reduce this risk. Weight-adjusted unfractionated heparin dosing and earlier performance of cardiac catheterization, for instance, would decrease infusion times, which may decrease bleeding risk.
The reviewer pointed out that previous analyses have shown that an invasive strategy was more effective in elderly patients with elevated troponin levels or high TIMI risk scores. Physicians could use these clinical markers to decide which patients would benefit most from an invasive strategy that includes earlier coronary angiography.
The ACP Journal Club review is online.
A federal advisory panel recommended 146 types of prescription drugs that should be covered when Medicare's new drug benefit begins next year.
The United States Pharmacopeia (USP), which sets pharmaceutical industry standards, recommended that prescription plans offer at least two drugs of each type, according to the Jan. 4 New York Times. Under the new Medicare law, beneficiaries will receive prescription benefits from private health plans.
Crafting the recommendations ignited controversy between drug companies and health plans, the New York Times reported. Whereas insurers want to limit the number and types of drugs covered to hold down costs, drug companies are pushing for more drugs to be included in drug formularies—a position supported by many physicians and patients.
The New York Times claimed that the USP's framework appears to favor insurers, although Medicare officials stressed that the government has the final say on which drugs will be covered.
The guidelines do not create separate categories for certain types of drugs, such as statins, selective serotonin reuptake inhibitors, COX-2 inhibitors or bisphosphonates. (Drug companies had advocated for that kind of classification.) As a result, insurers would not be required to cover particular drugs in these classes.
The USP suggested instead that drug plans cover at least one drug from each pharmacologic class (for example, the antidepressant category includes three pharmacologic classes: monoamine oxidase inhibitors, reuptake inhibitors, and other drugs such as bupropion and maprotiline) and be required to justify exclusions of particular drugs that have substantial scientific or clinical evidence. Insurers are not required by law to use the USP's framework. The federal government may strongly encourage them to do so, however, to make it easier for consumers to compare prescription plans from different insurers.
The USP recommendations are online.
The New York Times is online.
The College's comments on the USP's draft recommendations, which were issued last year, are online.
Starting this month, the CMS is surveying 7,400 Medicare providers, who will evaluate the services of their Medicare carriers and intermediaries.
The Medicare Contractor Provider Satisfaction Survey will allow providers to rate contractors in several different areas, including communications, claims processing, appeals, medical review and reimbursement. The survey fulfills a provision of Medicare reform legislation passed in 2003.
The CMS will pick the survey participants, which will include physicians, hospitals, end-stage renal disease clinics, laboratories and ambulance providers. The agency will not make the results available to the public, and individual providers will not be identified.
Data collection will continue through March 2005. The College has advocated for the CMS to establish some feedback mechanism so physicians can comment on contractors' services.
More information on the survey is online.
The business of medicine
A health information technology survey and evaluation firm has released the top-10 user survey ratings for 2004 for ambulatory billing and scheduling systems.
The firm, KLAS Enterprises LLC, had software users rate practice management systems according to 40 different performance criteria, including pricing and technology overviews. (KLAS works with ACP's Practice Management Center to provide College members with product evaluation and comparison data.) The top 10 practice management products for practices with six-25 physicians were, in descending order:
- Microsys Computing MicroMD
- NextGen EPM
- A4 Healthmatics PM
- IDX Groupcast (GPMS)
- WebMD/Medical Manager Intergy
- Misys Tiger
- LSS Practice Management
- GE Centricity Physician Office PM
According to KLAS, the same top three vendors were also chosen in a similar survey in mid-2004. While McKesson PPM and PulsePro were also highly rated, they did not meet KLAS's minimum standards for statistical confidence.
More information about KLAS reports and surveys is online.
ACP members who complete a short survey will have free access to limited KLAS summary reports or to discounted prices after buying the full reports. The ACP Practice Management Center's computers Web site also gives members resources to help them select practice management software.
A Medicare carrier has issued an alert, saying that a fraudulent group is trying to steal physicians' identification information to falsify patient enrollment and change addresses to which claims should be paid.
The carrier, Trailblazer Health, said that members of an organized group are posing as either Medicare fraud investigators or CMS employees from Medicare's audit, claims or enrollment units.
Callers claim they need to update physician information, sometimes saying that information has been lost due to a computer malfunction. They then ask for physicians' identification information, including Social Security numbers, unique physician identification numbers, medical license copies, and verifications of education and practice location.
The CMS has said that it has not suffered any computer malfunction nor is it calling physicians for information updates. Medical offices that receive such calls should try to verify the party's phone number and then notify their Medicare carrier of suspected fraud.
Trailblazer serves Colorado, New Mexico, the District of Columbia, Delaware, Maryland, Texas and Virginia.
More information is online.
The FDA last month approved the first laboratory test designed to test patients for genetic information that physicians should consider before prescribing some medications. Such information could help patients avoid harmful drug interactions or inappropriate medications.
The DNA microarray test, called the AmpliChip Cytochrome P450 Genotyping Test, screens DNA in blood samples to determine how well a patient's liver will metabolize certain drugs, according to an FDA news release. Variations in the cytochrome P450 gene affect the body's ability to break down drugs and other compounds.
The test, made by Roche Molecular Systems Inc., may help doctors select the appropriate types and dosages of many common drugs, including antidepressants, antipsychotics, beta-blockers and some cancer drugs, the FDA news release said. The test is the first microarray test to be approved and clears the way for the development of other genetic diagnostic tests.
The FDA news release is online.
The College has told the Drug Enforcement Administration (DEA) that its recent actions and statements leave physicians without clear guidance on dispensing controlled substances for pain treatment.
Last fall, the DEA abruptly withdrew formerly approved guidance on prescribing pain medication and then released an interim policy statement that addressed some of the issues in its previously posted policy.
According to a Jan. 4 letter to the DEA deputy administrator, College President Charles K. Francis, FACP, said that the DEA's interim statement failed to clarify important pain control issues. That clarification is needed, the letter stated, or physicians may feel compelled to limit the number of pain patients they treat.
The withdrawn guidance had made it clear, for instance, that the number of patients receiving opioids in a practice or the duration of pain therapy should not, in itself, trigger an investigation of a physician's prescribing practice.
The interim statement does not clarify the DEA's position on those issues, nor does it provide clear policy on the issues of refills and of family members' concerns.
In the letter, Dr. Francis said the absence of clear guidance "could have a chilling effect on appropriate pain care."
The letter is online.
For more on pain management, see ACP Observer's "Pain Management for the Internist" online.
ACP has joined more than two dozen other medical societies in asking the CMS to review the work relative value units of several evaluation and management (E/M) services, claiming that the amount of work involved in those services has increased significantly since the CMS last appraised them.
The Jan. 3 letter sent to CMS administrator Mark B. McClellan, FACP, listed codes for 11 different E/M services that signatories said are currently undervalued, including new and established office visits, initial and subsequent hospital care, critical care and office consultations. Those services are undervalued, the letter claimed, because the intensity, complexity and duration of the care needed to perform those services have increased.
The letter lists numerous changes since E/M service codes were last reviewed. Those changes include:
- A greater expectation that physicians will be more aggressive in preventing, diagnosing and treating disease.
- The growing need for additional documentation.
- An increase in the complexity of data and required care.
- The advent of online patient communications.
- The growing role of genomics in patient evaluation and management.
The letter listed other reasons why a new review of E/M work value units is needed, including the growing length of office visits and hospital stays. The letter also pointed out that the E/M work per unit of time "is less than the work per unit of time for almost any other service."
A link to the letter is online.
The ACP's Council of Associates (COA) and Council of Student Members (CSM) are calling for nominees to fill five seats on each council for the 2005-06 term, which begins May. Nomination submissions for both councils are due Feb. 15, with elections to be held in March. All candidates will know election results by March 15.
The COA seats available include those for the Northeastern, Southern, Mid-Western, Western and Uniformed Services zones. COA members help plan associate activities at Annual Session and develop Associates' resources on ACP Online.
CSM nominees are being sought for the following regions: Central, Central Atlantic, New England, North Atlantic and North Central. The CSM helps support student leadership within the College and expand student member programs in local, regional and national ACP activities.
Details about the COA's nominations process and zone demographics are online.
More information about the CSM's nomination process and regions 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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