In the News for the Week of 1-18-05
- College posts Web resource for tsunami relief
- State rankings affect surgeons' decisions
Clinical news in the headlines
- Highlights of the Jan. 18 Annals of Internal Medicine
- Blacks slower to recover from stroke
- New guidelines focus on aerosol delivery devices
- New CMS program helps seniors with flu drug costs
- More evidence that sleep deprivation impairs interns' judgment
- Supreme Court gives green light to class-action HMO suit
ACP products and services
- New College resource helps with ABIM exam prep
- ACP: CMS' quality improvement program needs financial incentives
- New CMS formulary review draft could threaten access
ACP's Annals of Internal Medicine has created a Web site with information on how physicians can donate aid and volunteer time for disaster relief.
According to the site, Project HOPE is working with the U.S. Navy hospital ship MERCY to provide assistance relief. The organization is seeking physicians and other medical personnel for assignment. The ship will be traveling to South Asia over the next three months to aid tsunami victims. Volunteers must meet specific medical and training requirements and commit to a minimum of 30 days overseas.
Long-term volunteer opportunities may also be available through Doctors of the World/Medecins du Monde, a nonprofit and nonsectarian organization that assesses how best to respond to disease outbreaks in areas affected by the tsunamis. The organization is also planning to help rebuild medical systems in those areas.
The new Annals site points out that physicians who want to volunteer overseas generally must have received previous training. However, physicians may be able to volunteer for disaster relief efforts within the United States by contacting their local Red Cross chapter.
The College's Web site also has links to other organizations, such as the U.S. Agency for International Development (USAID), the federal agency for international economic and humanitarian aid. The USAID site provides lists of charities that accept donations for tsunami recovery. The Web site also provides links to both College and outside resources on infectious diseases, infection control and other health concerns affecting tsunami survivors.
The new Annals of Internal Medicine's tsunami relief site is online.
The site is also accessible from PIER.
Newly-released results of surveyed cardiologists in New York found that physicians' concern over the state's publicly-disclosed performance data influence their decision on whether to perform angioplasty on high-risk patients.
The survey found that 83% of respondents said that some patients who might benefit from angioplasty don't receive the procedure because the state publicly reports heart surgeons' mortality rates. The survey also found that 79% of respondents claimed that public disclosure of mortality rates affected their clinical decision-making. Survey findings were published in the Jan. 10 Archives of Internal Medicine.
New York pioneered the use of publicly reporting physician performance data and began compiling data on cardiologists' angioplasty mortality rates in 1994, according to the Jan. 11 New York Times. Elective angioplasty has a less than 1% mortality rate, but a much higher rate when performed on high-risk patients, including those who are having a heart attack, are in shock or who have low blood pressure.
Cardiologists quoted in the article disagreed on whether public reporting of physician performance data improved patient care. Physicians who were quoted suggested removing mortality data on the sickest patients—those in coronary shock—from the performance database so physicians' rankings wouldn't be skewed.
The survey was sponsored by the University of Rochester Medical Center's School of Medicine and Dentistry. A Jan. 11 University of Rochester news release said that New York is one of only a handful of states that reports physicians' mortality rate data.
The Archives abstract is online.
The University of Rochester news release is online.
The New York Times is online.
Clinical news in the headlines
The following articles appear in the Jan. 18 issue of the Annals of Internal Medicine. Full text is available to College members and subscribers online.
A single fecal occult blood test (FOBT) provides poor screening. A study found that a single FOBT administered in physicians offices misses 95% of advanced precancerous lesions. According to the prospective study of more than 3,100 patients, a single FOBT identified only 4.9% of those with those lesions, compared to 23.9% who provided six stool samples taken at home.
A survey found that many physicians give patients a single FOBT in their office instead of having patients take a six-sample FOBT test at home, which is the current screening recommendation for FOBT. Patients often don't complete the home FOBT tests.
Improving HDL cholesterol slows heart disease progression. A new study found that giving patients with a low HDL level and known coronary artery disease drugs to boost their HDL level were able to lose weight, lower their total cholesterol and LDL levels, and suffer fewer cardiovascular events.
Because the anti-lipid drug regimen improved all lipid profiles, the study did not show whether disease progression was slowed by increased HDL or decreased LDL levels.
Results of a government study released last week found that African American stroke survivors had a higher incidence than whites of disabilities that prevented them from performing daily activities.
The study, part of the 2000-2001 National Health Interview Survey, found that 42.4% of African Americans reported severe functional limitations in walking up steps, compared to 28.6% of whites, according to the CDC's Jan. 14 Morbidity and Mortality Weekly Report (MMWR). African American stroke survivors were also more likely than whites to require special equipment to aid their recovery and to report problems standing, walking and bending.
With earlier studies finding that African Americans are at a higher risk for stroke than other groups, the new findings underscore the continuing health disparities in the prevention, treatment and control of high blood pressure and other risk factors for stroke, according to the report. The study's authors called for increased educational efforts in black communities on stroke prevention and on the importance of getting immediate stroke treatment.
The MMWR is online.
New guidelines conclude that different aerosol medication delivery systems, when used properly, are equally effective when prescribed for respiratory conditions, such as asthma and chronic obstructive pulmonary disease.
The evidence-based guidelines are the first to be developed jointly by the American College of Chest Physicians and the American College of Allergy, Asthma & Immunology. The guidelines were based on a systematic review of randomized controlled trials comparing metered-dose inhalers with or without spacers/holding chambers, dry powder inhalers and nebulizers, delivering both bronchodilaators and inhaled corticosteroids. The guidelines are published in the January Chest.
Because the different devices were found to be equally effective when used properly, the guidelines recommend that physicians base prescribing decisions on factors such as device availability, cost and convenience, and patient-related factors such as the patient's age, competence in using the device and preference.
The guidelines also include recommendations for selecting devices in specific clinical settings. Those recommendations include:
Inpatient setting. Nebulizers and metered-dose inhalers are appropriate.
Emergency department setting. Nebulizers and metered-dose inhalers, which have spacer/holding chambers, are effective in delivering beta-2 agonists.
Patients supported by mechanical ventilation. Careful attention must be paid to technical details of administrating medications by metered-dose inhaler or nebulizer because those factors can affect the efficacy of aerosol delivery.
The guidelines are online.
The CMS last week launched a demonstration project to help pay for antiviral medications taken by Medicare beneficiaries to prevent the flu. The project is designed to track how well such coverage can help seniors avoid serious flu complications, particularly among those who have no drug coverage.
The project, slated to run through May 31, 2005, will help pay for a maximum of two antiviral prescriptions per beneficiary. The four antivirals covered by the project are amantadine, rimantadine, oseltamivir, and zanamivir.
The CMS will pay 80% of antiviral prescription costs, up to the Medicare-allowed payment, for prescriptions filled at Medicare participating pharmacies, as long as beneficiaries have met their Part B deductible. Seniors who belong to a Medicare-approved drug discount card program will pay 20% of the card sponsor's negotiated cost or 20% of the Medicare-allowed payment, whichever is lower.
Medicare beneficaries in the transitional assistance program can use their drug credit for antiviral medicines, as can those in the Medicare Advantage plans.
More information is on ACP's Adult Immunization Initiative news Web page.
Study results released last week on the effect of sleep deprivation on medical interns found that working 24 hours or longer more than doubles interns' risk of getting into a car accident.
The study surveyed 2,737 interns nationwide. Participants were asked to fill out monthly reports providing details about their work hours, length of shifts, and any incidents involving a car crash, near-miss accident, or falling asleep at the wheel. The study appeared in the Jan. 13 New England Journal of Medicine (NEJM).
Interns who worked 24 consecutive hours or more were 2.3 times as likely to have a car crash and 5.9 times as likely to report a near-miss accident as interns who worked standard 12-hour shifts. For every extended work shift scheduled in a month, researchers found that the risk of an intern getting into a crash during the month increased by 9.1%.
Survey respondents routinely worked 30-hour-plus shifts and there were 274 reports of working more than 40 hours at a time, resulting in acute sleep deprivation for two consecutive nights, the researchers reported. An earlier study by the same researchers found that sleep deprivation also led to more medical errors, according to the Jan. 13 USA Today.
The Accreditation Council for Graduate Medical Education changed its rules in 2003—after study data were collected—to limit intern hours to no more than 80 hours a week averaged over four weeks. However, researchers noted that the rules still allow interns to work 30-hour shifts. Continuing to allow extended shifts, the study said, poses a serious safety risk to interns and other drivers.
The NEJM abstract is online.
USA Today is online.
Also see "Despite new work hour rules, residents need more rest" in the Dec. 2004 ACP Observer.
The U.S. Supreme Court last week declined to hear arguments in a physician class-action suit being brought against six of the nation's largest HMOs. That refusal allows the suit to go to trial.
The suit charges that HMOs conspired to underpay physicians between 1990 and 2002 by programming underpayment into health plan computer systems, according to the Jan. 11 Modern Physician. HMOs named in the suit include UnitedHealth Group, WellPoint, PacifiCare Health Systems, Humana and Health Net.
Two other defendants named in the original suit—Aetna and Cigna Corp.—have already agreed to a settlement that exceeds $1 billion. The trial has been set for Sept. 6 in Miami.
Modern Physician is online.
In related news, several medical trade organizations—including the Medical Group Management Association and the AMA—have reminded members that they have only one more month to submit claims for money owed them from the class-action settlement from Cigna Corp.
According to the Jan. 14 Modern Physician, Cigna will pay out about $70 million. Physicians must file claims by Feb. 18.
Modern Physician is online.
ACP products and services
Internists now have an updated resource designed to help them with ABIM certification or recertification preparation.
ACP's "Prep for Boards 2" supplements the College's MKSAP 13 program by focusing solely on the core content that is tested on the ABIM certification and recertification exams. The resource can help you assess your current knowledge of internal medicine and improve your test-taking ability.
"Prep for Boards 2" contains more than 500 Board-like multiple-choice questions with answers, references and evidence-based critiques that explain why each option is either right or wrong. "Prep for Boards 2" also contains more than 50 questions presented in an image-based format, which are modeled after questions on the ABIM exam. The CD-ROM "Prep for Boards 2" version includes a PDA companion application.
"Prep for Boards 2" is available in print, on CD-ROM or as a combination package. MKSAP 13 subscribers get 80% off the regular purchase price of either the print or CD-ROM version—and $100 off the package price.
More details and pricing information are online.
In its comments to the final draft statement on CMS' upcoming quality improvement organization (QIO) program, ACP strongly recommended that the CMS include in the program financial incentives for physicians. Those incentives are critical, the letter said, to encourage physicians to adopt information technology that would enhance quality improvement efforts and lessen physicians' exposure to financial risk.
The recommendation was one of several the College sent about the QIO program in a Dec. 28 letter. The letter applauded the QIO program's overall efforts to help integrate health information technology and redesign care management for patients with chronic conditions and preventive service needs. The College pointed out, however, that the QIO program will ask for extensive physician efforts—to implement certified products, report data on office quality measures, conduct improvement projects based on those measures, and report results back to the CMS—without any financial incentives.
ACP also said it was concerned about other issues included in the final QIO program statement. They include:
Giving quality improvement organizations a target percentage of practices to recruit. The current CMS proposal would allow QIOs to recruit an unlimited number of physician practices, only to have the CMS subsequently limit the number of offices a QIO can work with. Recruited physicians who are turned away, the letter said, may be reluctant to work with the QIO in the future.
Allowing physician offices to participate that don't already have an electronic health record (EHR) system. The statement places a strong focus on EHRs, the letter said, while QIOs should also be willing to work with practices that have adopted only some component of an EHR—such as e-prescribing software—to see how stand-alone tools can facilitate quality improvement efforts.
Defining more clearly the target level of performance being used in the program in selected quality measures. Target levels should be set, the letter said, based on avaiable evidence pertinent to physician practice.
Urging the CMS to take the lead in translating Medicare forms for patients into different languages and literacy levels, to promote quality improvement efforts among patients with limited proficiency in English.
The College's recommendations are part of ACP's ongoing effort to secure optimal financial and clinical incentives for internists to participate in quality improvement efforts.
The letter is online.
In a letter sent last week to CMS administrator Mark McClellan, FACP, the College said that the CMS needs to revise its proposed draft guidelines for the new prescription drug plan formularies mandated by the 2003 Medicare reform. Those guidelines, the Jan. 7 letter said, have "significant deficiencies" that need to be fixed.
The letter stated that the primary flaw is that the guidelines reflect current standard insurance practices and equate those with best formulary practices. Those practices, the letter noted, may be based too heavily on cost savings instead of on appropriate medical care, and could deny patients access to certain types of needed drugs.
To remedy those deficiencies, the College is advocating that practicing physicians participate in prescription drug plan pharmacy and therapeutics committees and that physicians approve plans' drug formulary. Without that participation, the letter pointed out, formularies run a much greater risk of encountering compliance problems.
The College further said that formularies should not be based solely on cost control; other factors that should determine which drugs should be covered include efficacy, safety and ease of administration. And the CMS guidelines need to ensure that physicians who prescribe non-formulary drugs without having to deal with a lengthy preauthorization procedure.
The College also said that formularies should be all-inclusive, and not limited to certain therapeutic categories of drugs, or those for particular diseases.
The letter is online.
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Copyright 2005 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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