In the News for the Week of 11-15-05
- ACP leaders present "In Their Own Words" statements on Capitol Hill
- Patient enrollment begins today for Medicare Rx benefit
Clinical news in the headlines
- Annals highlights: Condoms reduce genital herpes; blood clots in pregnancy can be deadly
- Cancer survivors lack adequate follow-up care
- Sleep disorder appears to increase risk of stroke
- Syphilis rate continues to climb
- Tighter oversight cuts improper payments in half
Health information technology
- Four groups chosen to start building national IT network prototypes
- Study claims that automation helps reduce Rx errors
- New report claims U.S. diabetes deaths may triple by 2025
- College reiterates policy on flu vaccine distribution amid some delays
- ACP revises procedures for ethical complaints
Last Thursday, ACP representatives joined those from other major national physician societies to hold meetings with key lawmakers on Capitol Hill. The meetings were to provide first-hand accounts from primary care physicians of how looming payment cuts will adversely affect them, their patients and their communities.
ACP leaders were joined by officials from the American Academy of Family Physicians and the American Osteopathic Association in presenting vivid "In Their Own Words" statements from physician members about looming cuts related to the flawed sustainable growth rate (SGR) formula. Eleven leaders from the three national societies met with Congressional staff for influential lawmakers who will have a direct say in Congress’ decisions on the SGR, bringing with them quotes from physicians in each of their states.
At the same time, group representatives met personally with Sen. Rick Santorum (R-Pa.), member of the Senate Finance Committee; Rep. Joe Barton (R-Texas), chair of the House Energy and Commerce Committee; and Rep. Michael Bilirakis (R-Fla.), member of the House Energy and Commerce Health Subcommittee.
College President C. Anderson Hedberg, FACP, and Michael C. Sha, ACP Member, Chair of the College’s Council of Young Physicians, were part of the group that met with Rep. Barton. Deepak Pradhan, ACP Student Member, a member of the College’s Council of Student Members, and J. Fred Ralston, Jr., FACP, Chair of the College’s Board of Governors, joined Dr. Sha in presenting information to Sen. Santorum. Lawrence M. Phillips, ACP Associate Member, Chair-elect of the College’s Council of Associates and a member of the College’s Board of Governors, rounded out the College’s diverse representation.
Leaders of the three groups, which together represent nearly a quarter-million physicians, agreed they received a mixed message from the Hill offices on the prospects for SGR relief. Lawmakers suggested that some form of relief--a year or two of positive updates--is still very much a possibility and that members of Congress are aware of the need to take action on this issue.
The overall message physician leaders heard was that physicians need to focus their contacts on House members, particularly on Republican representatives who should ask Rep. Dennis Hastert (R-Ill.), speaker of the House, to include relief from the cuts in legislation before Congress adjourns for the year.
The organizations also held a joint press conference on Capitol Hill to call attention to these activities. You can access all “In Their Own Words” campaign materials on ACP Online.
Today marks the day that all Medicare beneficiaries can begin enrolling in a Medicare Part D drug plan. The enrollment period extends until May 15, 2006.
Beneficiaries will have many plans from which to choose. Most areas have between 15 and 20 stand-alone Part D Prescription drug plans that each offers multiple options, as well as several Medicare Advantage prescription drug plans that combine drug coverage with physician and hospital health care benefits. Beneficiaries can get help choosing a plan by calling 800-Medicare, visiting www.medicare.gov or contacting their local state health insurance assistance program or local department of aging.
Current Medicare beneficiaries who choose not to enroll during this period and do not have drug coverage at least equal to the standard Medicare Part D benefit will have to pay a penalty if they later decide to enroll in a Medicare drug plan. (That penalty is 1% of the premium for each month the beneficiary delayed in joining a Part D program. The penalty will stay in effect as long as the beneficiary remains in the Part D plan.)
The College has developed a Web site that provides useful information about the new Part D benefit for you, your staff and patients.
For more information, see "Getting yourself ready for Medicare Rx" in the October ACP Observer.
The ACP Foundation has also added a Medicare Part D HEALTH TiPS to its patient education series to help physicians provide important information to their patients.
Unlike much of the information available to the public, HEALTH TiPS provides just enough important information for patients to begin to take action. The Medicare Part D HEALTH TiPS describe the two basic plans Medicare will offer, sources of additional information and help in choosing a plan, as well as important dates for enrollment.
Also available free through the Foundation’s Web site are HEALTH TiPS for pain, hypertension and healthy shelter living. The pain and hypertension pads, also available in Spanish, can be ordered on the Foundation’s Web site. The shelter living HEALTH TiPS can be downloaded.
HEALTH TiPS are also available at Chapter meetings. Stop by the ACP table and look for the brightly colored pads.
Clinical news in the headlines
The following articles appear in the Nov. 15 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
New study: Condom use reduces incidence of genital herpes. A study of 1,843 people at high risk for herpes infection found that those who used condoms more frequently had lower rates of herpes simplex virus-2.
An editorial says that while ongoing efforts seek to promote sexual abstinence, reduce risk-taking behaviors, and develop a vaccine and/or other preventive drug, condoms remain the best proven means to reduce the risk of sexually transmitted diseases.
Blood clot problems in pregnancy and postpartum are infrequent but dangerous. A study found that pregnant women and those up to three months postpartum had four times more blood clot problems, including deep vein thrombosis and pulmonary embolism, than nonpregnant women in the same age range.
The study reported that these rates are higher than previous estimates. Researchers looked at records of 50,000 women who were pregnant between 1966 and 1995. One hundred developed deep vein thrombosis, pulmonary embolism or both. The incidence of problems with venous thromboembolism increased with each trimester of pregnancy and was highest in the postpartum period.
Mothers age 35 and older in the first weeks after delivery had the highest risk for pulmonary embolism.
An editorial said that, however rare, pulmonary embolism during the last 20 to 30 years has become the leading cause of maternal death in the United States. The editorial also said that physicians need stronger evidence and more specific risk profiles before prescribing anticoagulant therapy for pregnant and postpartum women.
For more information, see "Medically managing your pregnant patient" in the November ACP Observer.
While advances in cancer care have allowed many more people to survive the disease, a new study reports that survivors rarely receive adequate follow-up care for what can often be long-term psychological and medical complications.
Primary care physicians rarely receive guidance from oncologists regarding the consequences of cancer, while there is also a lack of consensus on what constitutes best practices, said a Nov. 7 news release from the Institute of Medicine (IOM), which conducted the study. The report recommended that survivors receive individualized plans summarizing their condition, treatment and recommended follow-up care. The report also said survivors need other tools, such as support services and advice on how to prevent new or recurrent cancers.
The IOM report points to a shift from focusing solely on saving lives to treating cancer more like a chronic disease, said the Nov. 8 Chicago Tribune. The toxic treatments used to eradicate tumors also put survivors at risk for disease recurrence, heart disease, chronic inflammation and other problems, all of which require ongoing care.
Many survivors also experience social and psychological complications, the Chicago Tribune reported, such as anxiety and depression.
The report urged the medical community to develop guidelines for caring for cancer survivors. In addition, the report recommended increased insurance coverage for needed care and more research on the long-term problems of cancer survivors and effective treatments.
An Institute of Medicine news release is online.
The Chicago Tribune is online.
Having obstructive sleep apnea more than doubles the risk of suffering a stroke and of overall mortality, according to the results of a new study.
In the study, researchers for more than three years followed 842 patients—697 with sleep apnea—who had been referred to a sleep center. The incidence of stroke or death from any cause was 3.48 events per 100 person years in the sleep apnea group vs. 1.6 events per 100 person years in the control group. The study appears in the Nov. 10 New England Journal of Medicine (NEJM).
The study underlines the importance of screening patients for sleep problems, said the Nov. 10 Philadelphia Inquirer. Diagnosing and treating the disorder effectively could help combat stroke.
The risk of stroke appears to increase with the severity of the sleep apnea syndrome, the study’s authors said. In addition, they found that the association between sleep apnea and stroke risk was independent of other cardiovascular and cerebrovascular risk factors, including hypertension.
The risk of stroke persisted even among patients being treated for sleep apnea, the authors continued. However, they noted that the study was not designed to assess the effect of treatment and that many patients were older and had a high prevalence of cardiovascular risk factors. In addition, sleep apnea treatment—such as continuous positive airway pressure—often have low patient compliance or aren’t very effective, the authors noted.
The New England Journal of Medicine abstract is online.
The Philadelphia Inquirer is online.
Newly released government statistics report mixed results in reducing the rate of sexually transmitted diseases. Nationally, the number of syphilis cases has climbed for four years in a row, while the gonorrhea rate—which remains much higher than that for syphilis—has reached an all-time low.
The syphilis rate reached a low in 2000 but the rate of infection has since increased, with an 8% jump to 2.7 cases per 100,000 population between 2003 and 2004, according to a Nov. 8 CDC news release. The syphilis rate among men increased the most—by almost 12%—to 4.7 cases per 100,000 in 2004. A CDC analysis suggested that about 64% of all cases in 2004 were among homosexual men, up from 5% in 1999.
Among blacks, the syphilis rate increased by almost 17% from 2003-04 figures, after a several-year downward trend, the release said. The increase was attributed to a surge in cases among black men.
At the same time, the national rate of gonorrhea fell 1.4% from 2003-04 figures to 113.5 cases per 100,000, the CDC reported. However, efforts to further reduce occurrence of the disease have been complicated by increasing resistance to the first-line treatment, fluoroquinolone, especially among homosexual men, whose resistance was eight times higher than among heterosexuals. In addition, blacks continue to be disproportionately affected, with a rate 19 times higher than among whites.
Chlamydia was the most common infectious disease in 2004, with almost 930,000 cases, an increase of almost 6% from 2003-04 figures, the release said. Overall, the CDC estimated that 19 million sexually transmitted disease infections, including HIV, occur every year.
The CDC release is online.
The CMS reported last week that it has cut in half the number of improper claims paid compared to last year.
In 2004, 10.1% of fee-for-service Medicare claims payments were found to be improper, compared with 5.2% in 2005—a $9.5 billion savings, said a Nov. 10 CMS news release. Since a 14.2% error rate was reported in 1996, Medicare said it has taken steps to make payments more accurate, including implementing tighter oversight and educating contractors about proper documentation.
The CMS, which pays about 1 billion fee-for-service claims annually, reviewed about 160,000 claims in 2005 as part of its error rate testing program, the release said. The process led to identifying problem areas and targeting improvements. The large reduction in errors over the past year, according to the release, is mainly due to improvements in the no-documentation and insufficient-documentation error rates.
In addition to documentation errors, improper claims in 2005 involved medically unnecessary services and incorrect coding, the release said. The CMS is now requiring contractors to educate providers about the importance of submitting complete medical records; identify which providers have high error rates on overused billing codes; and develop local programs to address the causes of errors and take corrective action.
ACP maintains a dialogue with CMS to ensure that its actions in response to its improper payments studies are appropriate and do not impose an unnecessary burden on internists.
The CMS is in the process of developing a similar oversight plan to monitor improper payments for its prescription drug plan that takes effect in January.
The CMS news release is online.
Health information technology
The federal government last week awarded contracts to four groups charged with building electronic health record (EHR) prototype systems in 12 U.S. regions.
The contracts, which total $18.6 million, were awarded to groups led by Accenture, a technology management company; the Computer Sciences Corp., a computer design and integration company; IBM; and Northrop Grumman, an information technology company, said the Nov. 11 New York Times.
Each group plans to head up a consortium of companies and invest much more of its own resources to meet the government’s goal of linking physician offices, clinics and hospitals with interoperable networks.
The contracts call for creating 12 pilot programs that would include personal digital health records and offer physicians access to EHRs, diagnostic information and billing, said the New York Times. Each group is in charge of creating interoperable networks for three regions.
The 12 pilot regions include both urban and rural areas, the New York Times reported. The pilots are seen as a first step to creating a national health information network, although David J. Brailer, MD, the federal coordinator for health information technology, was quoted as saying the government is interested in these companies setting up competing networks. He pointed out that the administration's plan for moving to EHRs will be less directed by the government than in other countries, like Britain, where the National Health Service is financing the national network.
According to the New York Times, the approach championed by the Bush administration is conceptually much like automated teller networks at banks, which connect and share information so customers can handle transactions across the country.
The New York Times is online.
A new study reports that automated pharmacy tools, such as pill counters and scanners, are helping to reduce prescription errors in mail-order prescriptions.
The study, conducted by the prescription claims company Medco Health Solutions, showed fewer than 1,000 errors—a 0.075% error rate—on prescriptions filled at the company’s mail order pharmacies in 2003, according to the Nov. 10 Philadelphia Inquirer. The study of more than 21,000 randomly selected prescriptions found no serious errors, such as drug mixups. The most common error was incomplete or incorrect labeling.
The study, which was published in the November issue of Pharmacotherapy, compared its findings to a parallel study on retail pharmacies, which found a dispensing error rate of 1.72%, the article said. The Medco study looked at accuracy of dispensed prescriptions based on correct drug, strength and dosage, and compared dispensed medicines against original prescriptions.
The retail study involved 50 non-automated pharmacies in six cities, the Philadelphia Inquirer reported. About 6.5% of the errors found were serious among the almost 4,500 prescriptions studied.
According to industry groups, pharmacists are increasingly turning to automation as they look for ways to spend more time counseling customers and less time counting pills, said the Philadelphia Inquirer. A national pharmacy group said that 37% of its members were using automated dispensing equipment in 2004, twice as many as the previous year.
The Philadelphia Inquirer is online.
A new report offers grim estimates of the toll that diabetes will take on Americans in the next 20 years if the health care system fails to adequately prevent and treat the disease.
The report, from the Yale Schools of Public Health and Medicine, said that deaths from diabetes in 2025 could go from just over 200,000 in 2000 to 622,000 a year. Blindness from the disease could increase three-fold, while annual costs associated with the disease could hit $351 billion.
The report was released in conjunction with an initiative announced by the pharmaceutical company Novo Nordisk, which is partnering with ACP on a diabetes initiative. The company announced a nationwide plan to change how diabetes is viewed and managed, which calls for the following:
Removing barriers and disincentives, and advocating for changes to public and private health care and medical education systems. One plan would focus on better reimbursement for physicians who treat diabetes and other chronic diseases.
Providing incentives for higher quality care, including commissioning analyses and reports on incentive-based reforms.
Supporting medical education and training in chronic care, including diabetes education for endocrinology fellows and family physician residents.
Enabling patient education and self-care, including studies on coaching intervention and education for ethnic populations.
At Annual Session, the College announced that it was teaming with Novo Nordisk on a major diabetes initiative. The pharmaceutical firm has given the College a three-year multimillion-dollar grant that will be used to promote best practices in diabetes care and to create and distribute educational tools and information for health care professionals and patients.
A Yale/Novo Nordisk press release is online.
Information about the ACP-Novo Nordisk initiative is online.
An Observer Special Focus on diabetes is also online.
With recent reports of inadequate distribution of flu vaccine, the College is once again calling attention to ACP's policy on flu vaccine distribution.
According to the November "CDC Immunization Works" newsletter, some health care providers have not received their ordered vaccine while others have received only a portion of their order. Some vaccine shipments have been delayed, the newsletter said, so physicians are urged to continue to vaccinate patients into December as vaccine becomes available.
Often, the number of influenza cases peaks in January and February, according to the CDC. More than 80 million doses of influenza vaccine were manufactured for this season, and more than 57 million doses had been distributed as of the end of October.
ACP's policy was approved last year to inform national policy-makers during times of flu vaccine shortages. The policy noted that access to an adequate supply of flu vaccine is critical for internists, because many of their patients are at high risk for complications from influenza due to either chronic health conditions or age. During previous flu seasons, much of limited flu vaccine supplies has gone to non-professional distributors, such as drugstores, that distribute the vaccine on a first-come first-served basis, regardless of risk.
ACP's recommendations include the following:
Flu vaccine manufacturers, non-professional distributors and appropriate government agencies should ensure that limited supplies are made available to clinicians and other licensed health care providers who provide regular patient care to high-risk individuals.
The CDC should continue to recognize that internists treat many seniors and patients with multiple chronic conditions, two groups the CDC has historically labeled as high-risk. The physician’s office is often the best location to get a flu shot, especially for those who can't stand in line at other venues and who require careful monitoring.
Local public health departments need an established plan to distribute vaccine to local providers with the greatest need.
Physicians should not be penalized for failing to follow emergency orders that are not clear and timely and do not provide for due process to resolve situations outside the physician’s control.
The CDC should have the authority to organize vaccine distribution and implement a concentrated response system, particularly in emergency situations.
The federal government should build and maintain a six-month stockpile of prioritized vaccines.
The CDC newsletter is online.
The College's flu vaccine policy is online.
The College has revised its procedures for addressing ethical complaints against ACP members. Those procedures apply to the entire College membership, including international members.
The procedures are implemented when ACP receives a formal complaint from a member physician, non-member physician or layperson regarding unprofessional, unethical or illegal conduct on the part of an ACP member, or when information requiring review is otherwise brought to the College's attention.
Ethical complaints against College members should be submitted to ACP's Executive Vice President or ACP's Center for Ethics and Professionalism. Formal complaints must be in writing and signed by the complainant, and must describe the particular act or conduct in question. Complaints will be forwarded along with any supporting documentation to ACP's President and the relevant chapter Governor.
Recent changes to the procedures address reviewer conflicts of interest, clarify possible sanctions and extend deadlines for international cases. Effective immediately, the revised procedures are online. For a printed copy of the procedures, contact Laura Gregory at 800-523-1546, ext. 2839.
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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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