In the News for the Week of 11-1-05
- Internists asked to share their stories on looming pay cuts
- Florida hospitals, physicians scramble to deal with demand
- CMS announces voluntary quality reporting program to start in 2006
Clinical news in the headlines
- Annals: childhood cancer survivors, cardiac rehab programs
- Mammograms, new treatments lead to fewer breast cancer deaths
- CDC: Diabetes affects 7% of U.S. population
- Hospitals treating black patients have higher heart attack death rates
Flu season alert
- Tamiflu maker halts shipments over fears of hoarding
The business of medicine
- Greater use of generics could save $20+ billion a year
- New Jersey sends checks to hard-hit specialists
- Certification organization seeks executive director
- College supports proposed update, pushes SGR reform
- College testifies to FDA against direct-to-consumer advertising
- Education campaign targets Latinos on heart health
ACP needs your help to increase the pressure on Congress to halt the Medicare payment cuts. The College is initiating a new “In Their Own Words” campaign to communicate what scheduled payment cuts will mean for physicians, patients and communities if they take effect Jan. 1.
The College is seeking short personal stories from physicians about the impact of the proposed cuts. Stories will be compiled and formatted into testimonials from each state. Sample stories are included online. ACP wants to include stories from various perspectives, including medical students, young physicians, practicing internists, internists nearing retirement and physicians in different practice settings.
ACP leaders will deliver those testimonials to members of Congress during a special “In Their Own Words” Day on Capitol Hill early this month. The goal of the campaign is to let Congress know the real and personal impact of the Medicare cuts on their constituents, both physicians and Medicare beneficiaries. Crucial decisions about Medicare will be made in the few days left before Congress adjourns for the year.
Please send your “story” to Tracy Novak by Monday, Nov. 7 and forward this request to other physicians or medical groups. You can also contact Tracy at 800-338-2746, ext. 4532, if you need help crafting your story.
Time is running out to contact your federal legislators before Congress adjourns. Take action through the College's Legislative Action Center.
South Florida hospital emergency rooms were overflowing into parking lots last week in an attempt to handle a surge in demand following Hurricane Wilma.
Patients with chronic diseases lost access to their prescriptions and their physicians, while power outages knocked out medical devices and people suffered from stress-related heart attack symptoms, said the Oct. 28 Miami Herald. FEMA officials were setting up makeshift clinics outside of several hospitals, staffed by volunteer health care teams.
The temporary emergency shelters and volunteer teams were expected to stay in place for as long as a month, the article said. Hurricane Wilma caused power outages at every hospital in Broward and Miami-Dade counties, while some also lost water or had to move patients due to structural damages.
According to James W. Loewenherz, FACP, a nephrologist in South Miami, Hurricane Wilma differed markedly from other recent hurricanes.
"Storms usually hit tighter geographic areas, so you could find cooperative facilities 30 miles away to care for your patients," Dr. Loewenherz told ObserverWeekly. "This storm affected half the state at one time, so we couldn't use any of the agreements we had." With 70 patients who needed to be dialyzed every other day, Dr. Loewenherz and his colleagues were able to find resources at cooperating hospitals and outpatient clinics with stand-alone generators so that most of his patients could receive dialysis.
While power was restored at most hospitals fairly quickly, some had to get emergency fuel delivered to keep generators running, the Miami Herald reported. Some patients eligible for discharge couldn’t leave because they didn’t have power or water at home and needed to operate IVs or oxygen machines.
One hospital chain flew in nurses from Dallas, Nashville and Atlanta, said the article, because local employees were unable to get to work. Some hospitals were forced to move emergency beds into pre-op and outpatient rooms.
The Miami Herald is online.
For more information on how to help victims of Hurricane Wilma, go to the Annals of Internal Medicine’s “Recent Hurricanes” resource page.
Medicare last week announced the launch of a voluntary quality reporting program for physicians to begin next year.
The first phase of the "Physician Voluntary Reporting Program," to be launched in January 2006, asks physicians to voluntarily report to the CMS on a set of evidence-based quality measures, according to an Oct. 28 CMS news release. The 36 measures were proposed by the CMS based on measures from several different sources for several specialties.
A subset of these measures was endorsed by the Ambulatory Care Quality Alliance (AQA), of which the College is a key member, while most of the measures have been derived from ones approved by the National Quality Forum (NQF). Several have been modified from hospital-based NQF measures, while all have an additional metric related to an exclusion criterion that was not part of the original NQF version.
In the program's first phase, the CMS will collect data from physicians through the use of healthcare common procedure coding system codes, or “G-codes,” the CMS release said. The new G-codes will supplement claims data that doctors currently submit with clinical data, which will be used to measure quality of care.
The G-codes are intended as an interim step until the widespread adoption of electronic health records, when electronic data submission will become the norm, according to the release. The CMS said it will collaborate with participating physicians to develop electronic data submission methods. The agency also plans to phase in additional quality measures as they are approved by the NQF.
Physicians who participate will receive feedback on their performance levels by the summer of 2006, according to the CMS release. That feedback will be used to help physicians improve their data accuracy, reporting rate and clinical care, as well as to solicit input from doctors on reporting methods and the usefulness of the quality measures.
The voluntary reporting program is patterned after the CMS’ hospital reporting program, which evolved into Hospital Compare, the CMS said. That program allows consumers to go online to compare quality reports on hospitals in their area.
The CMS has not indicated whether this demonstration project will eventually evolve into a pay-for-reporting or pay-for-performance demonstration project and there has been no indication about the potential for public reporting based on these voluntary measures.
The CMS news release is online.
For more information on the AQA, see "Market forces push pay for performance" in the May ACP Observer.
Clinical news in the headlines
The following articles appear in the Nov. 1 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Childhood cancer survivors often have performance limitations. A study of 11,481 childhood cancer survivors found that 20% had a physical performance limitation compared with 12% of their siblings who did not have cancer. Six times as many survivors, compared with siblings, could not attend school or work. Among survivors surveyed, those who had had brain and bone cancer were the most severely affected.
Authors pointed out study limitations, including the fact that cancer treatment techniques have improved over the past 20 years. However, they stressed that adult survivors of childhood cancer should be monitored for functional loss throughout their lives and referred for appropriate rehabilitation services.
Cardiac rehab improves survival rates after heart attack. A meta-analysis of the effect of cardiac rehabilitation programs after heart attacks found that people who participated in such programs lived longer and had a better quality of life than those who did not participate.
The programs are called secondary-prevention programs because they take place after an illness and seek to prevent disease recurrence or progression. Program options included education and counseling about coronary risk factors; education plus supervised exercise programs; and structured exercise programs alone.
Researchers found benefits associated with all program types. Overall, the programs positively affected risk factor profiles, such as blood pressure and cholesterol, while they also improved functional status or quality of life and reduced subsequent heart attacks by 17% over a one-year follow-up period.
A large study by the National Cancer Institute concluded that mammography has played a significant role in bringing down the number of deaths from breast cancer in recent years.
The study, which relied on statistical models developed by seven cancer research centers nationwide, found that mammography screening accounted for between 28% and 65% of the overall decrease in breast cancer deaths from 1975 to 2000. The remaining percentage decrease was due to treatment advances. The study appears in the Oct. 27 New England Journal of Medicine (NEJM).
Prior to the study, some experts disagreed over whether mammograms were cost effective and worth the risk of false positives or finding non-malignant tumors, said the Oct. 27 New York Times. However, other experts claimed that mammograms were crucial to finding cancers early and treating them effectively.
According to the study, the breast cancer death rate hovered at just under 50 per 100,000 women between 1975 and 1990, but then fell dramatically to 38 per 100,000 by 2000, a decrease of 24%. That reduction coincided with an increase in the number of women undergoing mammography screening, which included 70% of women over age 40 in 2000. It was unclear, however, how much of the decrease was due to screening and how much to the increased use of adjuvant chemotherapy and tamoxifen.
The debate over mammograms began in the 1980s when the National Cancer Institute questioned routine screening for women in their 40s, the New York Times said. Subsequent clinical trials did not provide clear evidence that finding cancers early through screening had an impact on the decline in deaths. However, the authors of the current study concluded that screening and therapy have worked together to bring about a lower death rate.
A NEJM abstract is online.
The New York Times is online.
Nearly 21 million Americans, or 7% of the U.S. population, have diabetes, according to new government figures, while 6 million of those do not know they have the disease.
The data, released last week by the CDC, also show that 1.5 million people age 20 and over are expected to be diagnosed with diabetes in 2005, according to an Oct. 26 CDC fact sheet. In addition, the disease is about twice as common among minorities as among whites and the risk of developing it increases with age.
People with undiagnosed diabetes are at particularly high risk for blindness, heart disease, limb amputations and kidney failure, said the Oct. 27 Atlanta Journal-Constitution. According to CDC estimates, one out of every three Americans born in 2000 will develop diabetes.
The country spends about $132 billion annually on the disease, with $92 billion of that in medical costs and the other $40 billion in missed work or lost productivity, the CDC said. The agency also noted that about 41 million people have pre-diabetes, which increases the risk of developing type 2 diabetes.
The CDC fact sheet is online.
The Atlanta Journal and Constitution is online.
For more on diabetes diagnosing and treatment, see "Special Focus: type 2 diabetes" from the November ACP Observer.
A patient's risk of dying after a heart attack is significantly higher in hospitals that treat a higher percentage black patients, according to a recent study.
Researchers compared 90-day mortality rates after acute myocardial infarction (AMI) for hospitals with a high number of black patients vs. those with low black populations. The study, which included about 1.3 million Medicare fee-for-service patients hospitalized between 1997 and 2001, found that hospitals with the highest percentages of black AMI patients (33.6%) had a 90-day risk adjusted mortality rate of 23.7%, compared with 20.1% for patients in hospitals that treated no black patients during the study period.
The study also found that close to 70% of all black patients were seen in only 21% of the hospitals, suggesting that receiving care at poor-performing hospitals is a more likely explanation for outcome disparities than the notion that blacks and whites are treated differently at the same hospitals. The study appears in the Oct. 25 Circulation.
The authors noted that a potential limitation of the study was not knowing the underlying conditions of patients in hospitals serving a higher proportion of black patients, which—if worse than average—could indicate that poor health was a factor in the higher mortality rate. They also noted that these hospitals tended to be located in low-income neighborhoods, suggesting that socioeconomic status affected outcomes.
The authors concluded that reducing mortality rates in high-mortality hospitals could lessen racial disparities. They suggested targeting quality improvements at hospitals serving large populations of blacks and directing patients living in urban areas toward high-quality hospitals.
The Circulation article is online.
ACP's "Racial and Ethnic Disparities in Health Care," which outlines steps to take to reduce disparities, is online.
Flu season alert
The maker of the antiviral drug Tamiflu announced last week that it had temporarily stopped shipments in the United States over fears that customer hoarding might threaten flu season supplies.
Roche Holding AG officials were concerned that private companies and organizations were starting to hoard Tamiflu supplies in case the H5N1 strain—avian flu—becomes a worldwide pandemic, according to the Oct. 28 Washington Post. The company stressed that the suspension would not affect government orders aimed at creating a national stockpile of the drug, which is believed to be the best defense against avian flu. The strain has killed more than 60 people in Asia.
The U.S. Senate last week approved nearly $8 billion to aid stockpiling of vaccines and other drugs, the Washington Post said. To date, the government has awarded a $62 million contract to Chiron Corp. and a $100 million contract to Sanofi-Aventis to produce avian flu vaccines.
According to the article, the number of Tamiflu prescriptions has quadrupled in the past year. The AMA has warned people not to stockpile the drug, fearing that misuse could cause drug-resistant influenza strains.
The Washington Post is online.
The business of medicine
More than $20 billion in drug costs could have been saved last year if doctors prescribed generic drugs instead of brand names, according to a new report.
The report—from pharmacy benefit manager Express Scripts—was based on a survey of 3 million commercial members and looked at six major drug classes, including antidepressants and cholesterol-lowering agents, said the Oct. 25 Washington Post. The report said that appropriate use of generics could lower the cost of gastrointestinal drugs, for example, by $5.4 billion a year. Generic gastrointestinal drugs were found to be dispensed 31% of the time even though a generic alternative would have been appropriate for 95% of prescriptions.
The report also estimated that $24 billion in savings would be lost this year and $25 billion in 2006 if generic use does not increase, the Washington Post said. An average generic drug costs about $60 less per month than a brand name drug, according to the report, and typically carries lower copays.
Over the next five years, the Washington Post noted, more than $50 billion in brand-name drugs will lose patent protection. Next year, for example, Merck’s cholesterol drug simvastatin will face generic competition, along with 14 other branded drugs.
An Express Scripts official quoted in the article noted that patients often feel uncomfortable asking their doctors about generic alternatives. In addition, the article said, doctors who receive samples from drug companies lack incentives to prescribe generic alternatives. However, a pharmaceutical industry representative noted that doctors are often justified in prescribing branded drugs because of differences among drugs in a therapeutic class and individual needs of patients.
The Washington Post is online.
New Jersey last week began sending subsidies to physicians hit hard by high malpractice insurance premiums.
About 1,200 neurosurgeons, obstetricians and radiologists will each receive nearly $11,000 in an effort to prevent shortages in those specialties, said the Oct. 26 Philadelphia Inquirer. The money is from the state’s Medical Malpractice Liability Insurance Premium Assistance Fund, funded by $75 annual fees paid by physicians, chiropractors, podiatrists, optometrists and lawyers, and by a $3 per employee yearly fee charged to businesses.
Sixty-five percent of the fund goes to premium subsidies while the rest goes to New Jersey FamilyCare health insurance program, hospital charity care and medical student loan relief for graduates who agree to practice in the state, the Philadelphia Inquirer said. The fund was created in response to spiking malpractice premiums in recent years that medical groups blame for many specialists retiring or moving to other states.
The Philadelphia Inquirer is online.
The Certification Commission for Healthcare Information Technology (CCHIT), an information technology certification organization, is looking to fill its executive director position for the organization. The position would be based in Chicago.
Founded in 2004, CCHIT is working to develop a certification process for ambulatory electronic health records (EHRs). CCHIT has been awarded an HHS contract to develop and evaluate certification criteria and an inspection process for EHRs.
Executive director candidates should have experience in business and start-ups, technical expertise in healthcare and information systems, and experience working with boards and volunteer experts.
Interested candidates should contact the organization via e-mail or by phone at 312-876-9800.
In a recent letter sent to the chair of the Senate Finance Committee, ACP said it supported the chair's recent inclusion of a 1% positive Medicare payment update for physicians for 2006 in the Senate's budget reconciliation, saying the proposed increase was a "welcome improvement" over scheduled payment cuts.
The letter pointed out, however, that a 1% increase—if it is approved—would be less than inflation. The letter also said that while ACP strongly supports the goal of linking Medicare payments to improved quality, a 1% increase would not give physicians the resources they need to invest in information technology to help track quality improvements.
The letter, signed by College President C. Anderson Hedberg, FACP, cited a Rand Corp. study that found acquiring electronic health records to facilitate quality improvement and reporting costs on average $33,000 per physician. At the same time, Dr. Hedberg wrote that a 1% fix, even if approved, would do nothing to avert cuts of between 4% and 5% scheduled under the flawed sustainable growth rate formula for January 2007.
The letter is online.
ACP is advocating that the FDA ban all direct-to-consumer (DTC) advertising, claiming that such marketing adversely affects internists' primary patient base: Medicare patients who have several medical problems.
In a statement for the record sent to an FDA public hearing this week, the College said that the FDA should at least strengthen existing voluntary guidelines. The College has voiced its opposition to DTC advertising since 1998.
The statement noted that DTC ads often leave patients confused and misinformed, forcing physicians to spend valuable office visit time explaining why a particular drug is inappropriate. That dynamic adds a subtle but chronic adversarial element to the physician-patient relationship, the statement said.
The statement also cited a 2000 Federal Trade Commission report, which found that doctors wrote 25% more prescriptions for the 50 most heavily DTC-advertised drugs, compared with 4.3% more prescriptions for all other drugs combined. Referring to the new Medicare Part D program slated to start Jan. 1, the College noted that if DTC ads continue to generate inappropriate demand and use, they could cost the federal government billions of dollars.
In the statement, the College acknowledged the need for the pharmaceutical industry to market its products, the statement said, but believes such efforts should be directed at increasing awareness among clinicians about new medication therapies, rather than to patients.
The statement also said that drug companies need to find more effective ways to communicate information on untreated conditions and that the government should continue to fund studies to measure the impact of DTC ads.
The statement is online.
This month, ACP is launching a major public relations campaign to educate Latino patients on heart health and cardiovascular disease.
Kicking off in Miami, the campaign will also target television and print media in Boston, Chicago, Houston, Los Angeles, New York, Philadelphia, San Antonio and San Francisco. The campaign will highlight ACP's newest patient education video and guidebook, "Guide to a Healthy Heart for Latinos," which is now available free to ACP members. ACP members in the target cities have volunteered to serve as spokespersons for the campaign.
The 30-minute DVD is designed to show patients how to manage their blood pressure, cholesterol and weight. It also includes tips on healthy eating, active living, the importance of smoking cessation and diabetes' role in heart disease.
The free bilingual English and Spanish DVD and guidebook are available to members through ACP Customer Service at 800-523-1546, ext. 2600, or online. Shipping and handling fees apply.
The guidebook can also be downloaded at no charge on ACP's patient education Web site.
About ACP ObserverWeekly
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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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