In the News for the Week of 11-22-05
- ACP Associate presents young physicians' perspective in Congress
Clinical news in the headlines
- Lifestyle changes plus drugs lead to greater weight loss
- ACP Journal Club: Vaccine reduces risk of shingles in older adults
- HIV rates still much higher among blacks than whites
Pay for performance
- CMS: Hospital bonuses linked to improved care
- More spending does not equal better hospital care
- Toolkit, materials now available for mental health screening
THERE WILL BE NO 11-29-05 OBSERVER WEEKLY EDITION.
Vineet Arora, ACP Associate Member, told House members last week that Congress must act now to stabilize Medicare physician payments to avert a looming crisis in primary care.
Dr. Arora, who is Chair of ACP’s Council of Associates and a member of the College’s Board of Regents, was invited to testify on the impact that scheduled payment cuts would have had on her career decisions as a young physician. She told the House Energy and Commerce Committee's subcommittee on health that medical students and young physicians are turning away from primary care careers.
“In my own program, I was one of only two of our nearly 30 graduating residents that did not enter a subspecialty training program,” said Dr. Arora. Medical students and young physicians, she added, learn early on in their training "that primary care is under-reimbursed compared to other specialties, and that many primary care physicians are struggling financially."
Because of reimbursement issues, she said, attending physicians in training programs often counsel residents to not go into primary care. Those financial problems will be exacerbated by scheduled payment cuts, which would total 4.4% as of Jan. 1, 2006, and more than 26% from 2006 to 2011, she pointed out. She told subcommittee members that the CMS' Medicare Economic Index estimates that physician costs will rise by 15% during the same five-year period.
Dr. Arora also cited CMS data showing that almost half of all Medicare office visit expenditures in 2004 were for services provided by primary care physicians. She said there is growing evidence that shortages are developing among U.S. physicians, particularly in general internal medicine and family practice. Those shortages are coming at a time when aging baby boomers will increasingly need health care services.
ACP’s testimony was prepared in conjunction with the American Academy of Family Physicians and the American Osteopathic Association, which submitted their own written statements.
More information on Medicare payment cuts and Dr. Arora’s testimony are online.
PIER recently published its 400th module, providing evidence-based clinical guidance on more than 286 diseases and conditions. PIER modules also include information on screening and prevention, ethical and legal issues, complementary and alternative medicine, and common procedures. PIER is also being used in national continuing medical education programs.
PIER has also made changes to the Web site's interface to streamline navigation and provide faster access to content. You can save PIER to your desktop by opening PIER in your Web browser and dragging the PIER icon that appears in the URL address box to your desktop.
The American Academy of Family Physicians has approved PIER as an evidence-based resource for use in continuing medical education applications and programs. PIER is also an approved resource of the National Board of Medical Examiners.
Recently added PIER topics include:
- Anal cancer
- Basal cell carcinoma
- Benign paroxysmal positional vertigo
- Chest X-ray
- Chronic pancreatitis
- Cluster headache
- Crohn's disease
- Lasik eye surgery
- Multiple sclerosis
- Perioperative management of adrenal insufficiency
- Pneumocystis carinii pneumonia
- Renal tubular acidosis
Physicians can now buy the 25 best-selling recorded sessions from Annual Session 2005 at 25% off their original price.
For a limited time only, physicians can order recordings in audiocassette, audio CD and MP3 CD formats at the discounted price. Individual recordings are now $12.75, down from $17. For even greater savings, buy the entire package of top 25 recordings for $195 and save $124 off the single title price.
Some of the popular sessions being offered cover diabetes outpatient management, drug interactions, hyperlipidemia, preoperative care and anticoagulation therapy. Recordings include several Updates and Clinical Pearl and Meet the Professor sessions.
More information is online or call 800-241-7785.
Clinical news in the headlines
A recent study on obesity reinforces the importance of combining weight-loss drugs with diet and exercise to maximize weight loss.
In the study, 224 obese adults received either 15 mg of sibutramine daily, some with and some without lifestyle counseling, while others received counseling alone. All were prescribed exercise and a diet of between 1,200 and 1,500 calories per day.
After one year, the group that received combined medication and group therapy lost the most weight—12.1 kg, more than double the amount lost by those who received either drugs or counseling alone. The results appear in the Nov. 17 New England Journal of Medicine.
The study emphasized that medications plus lifestyle changes and behavior therapy work better than either one alone, the authors said. Subjects who took sibutramine and kept diaries of what they ate lost the most weight, they noted, pointing to the importance of modifying eating habits.
The study, backed by the National Institutes of Health, is the largest to date on combining lifestyle modifications with weight loss drugs, said the Nov. 17 Philadelphia Inquirer. The researchers recommended that future studies look at whether doctors could provide more comprehensive counseling over longer periods. Counseling consisted of 30 separate 90-minute group therapy sessions, the article noted, but these involved extra time and expense for patients.
An accompanying editorial recommended that physicians carefully evaluate obese patients before prescribing weight-loss medications. Medications may be preferred for patients at high risk for obesity-related disease, the editorial said, but drugs should be given in conjunction with behavioral therapy.
The New England Journal of Medicine abstract is online.
The Philadelphia Inquirer is online.
Older adults in a shingles prevention trial who received a varicella-zoster vaccine were significantly less likely to develop herpes zoster and postherpetic neuralgia.
The five-year study included more than 38,500 adults age 60 or older who had a history of varicella or who lived in the United States for more than 30 years. Participants received either 0.5 ml of varicella zoster vaccine or placebo. Those who received the vaccine had a 51% reduced risk of contracting herpes zoster and a 67% reduced risk of postherpetic neuralgia.
The study, abstracted in the November-December ACP Journal Club, may be the first to examine a vaccination strategy aimed at reducing risk for a disease caused by a latent infection acquired decades earlier, said reviewer Thomas Fekete, MD, of Temple University School of Medicine in Philadelphia. An effective vaccine is significant because postherpetic neuralgia is associated with high morbidity, and affected patients often must make multiple office visits and purchase antiviral drugs and analgesics.
The vaccine appears to be safe and effective because it caused few adverse advents, he noted. If the vaccine becomes available to older adults at a cost similar to the pediatric vaccine, there is a strong argument for administering it universally without regard for individual risk factors.
This study does not determine the optimal age for administering the new vaccine nor how long the protection lasts, said Dr. Fekete. In addition, the study did not address safety and efficacy in immunocompromised adults, although the pediatric vaccine has proven fairly safe in children with moderate immune deficiency.
Peer ratings for this article: general internal medicine/family practice/general practice: 6/7 stars; infectious disease: 7/7 stars.
ACP Journal Club is online.
According to newly released government figures, the rate of HIV infections has declined but blacks are still much more likely than whites to contract the disease.
The report by the CDC found that while the rate of HIV cases in blacks has been declining steadily since 2001, blacks are still eight times more likely than whites to be diagnosed with the disease, said the Nov. 18 Philadelphia Inquirer. The study of data from 33 states found that the overall rate of diagnoses fell from 22.8 cases per 100,000 population in 2001 to 20.7 per 100,000 in 2004.
Despite the persistent racial disparity, the decline in cases was sharper among blacks, the article noted, from 88.7 cases per 100,000 population in 2001 to 76.3 per 100,000 in 2004, compared with a slight increase among whites.
CDC officials attributed part of the decline among blacks to a 9% annual decrease in cases among intravenous-drug users, more than half of whom were black, said the Philadelphia Inquirer. Another factor was a 4% decline among heterosexuals, with blacks making up almost 70% of heterosexuals diagnosed with the disease.
In a Nov. 17 news release, CDC officials noted that the new study is more representative than those in years past because it includes data from New York state, which accounted for 20% of new HIV cases during the study period. Officials urged more states, such as California and Illinois, to adopt confidential name-based HIV reporting systems to more accurately track disease rates.
More efforts are needed to prevent infection among black homosexual men, the group hardest hit by the disease, said the CDC. The agency said it is committed to helping black communities set up prevention programs and to ensuring access to early testing and treatment.
A CDC news release is online.
The Philadelphia Inquirer is online.
Pay for performance
The CMS last week reported positive results for its inaugural hospital pay-for-performance program, suggesting that tying hospital payments to quality standards improves overall care.
In its first payout for a three-year pilot program that began in 2003, Medicare paid the top 123 hospitals an additional $8.85 million, the Nov. 15 New York Times reported. Overall, the 270 participating hospitals improved their performance scores by an average of almost 7% based on 33 clinical measures.
The clinical measures targeted five disease areas: acute myocardial infarction, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacement, according to a Nov. 14 CMS news release. Hospitals received bonuses based on how well they met evidence-based measures related to each condition.
The highest composite scores were for heart attack, with scores improving from 87% to 91% in the first year, the CMS said, while the biggest percentage improvement (from 69% to 79%) was for pneumonia care. Hospitals that ranked in the top 10% of a disease category were given a 2% bonus while those in the second 10% received 1% bonuses, the release said. Hospitals in the bottom 10% or 20% for a given condition at the end of the pilot phase will receive a reduction of between 1% and 2% in their Medicare payment.
Only two hospitals were in the top two tiers for all five clinical areas: Hackensack University Medical Center in Hackensack, N.J., and McLeod Regional Medical Center in Florence, S.C., the CMS said. Hackensack University Medical Center received the largest single award—$326,000 for bypass patient care—and its total awards were about $847,000.
The CMS news release is online.
The New York Times is online.
A newly released study on California hospitals found that higher per-patient Medicare payments to hospitals for chronic care did not translate into better results or happier patients.
The study used claims data on Medicare beneficiaries who died in 226 California hospitals between 1999 and 2003, said a Nov. 16 news release from the Robert Wood Johnson (RWJ) Foundation, which cosponsored the study with the California HealthCare Foundation, an independent philanthropy focused on better health care delivery. Researchers found that some hospitals were paid four times more than others to care for patients with similar illnesses, but did not have better outcomes.
Among the study’s other findings:
most of the variation in hospital payments was attributable to the volume of care—how many times a patient was admitted and how many days he stayed—not to a hospital’s daily rates.
both quality and patient satisfaction declined with a hospital's volume of care.
improved efficiency could have saved $1.7 billion in Medicare payments over five years in Los Angeles alone.
The study concluded that the volume of inpatient chronic care is driving cost and that Medicare should shift from focusing on acute care to funding a chronic care infrastructure that rewards system-wide efficiency, the RWJ release said. The authors recommended that efficiency savings be shared among payers and providers.
They also urged that hospital-specific information on chronic care efficiency be made available to payers and employers, who would use it to steer patients away from high-cost hospitals to more efficient ones.
The RWJ news release is online.
Physicians can now download free mental health diagnostic and treatment aids to help screen patients for a variety of mental health conditions, including depression and bipolar disorder. The toolkits are being offered by Screening for Mental Health (SMH), a nonprofit organization that introduced the first national mental health screening day 14 years ago.
Toolkit materials are designed to help physicians conduct screening and provide diagnosis and treatment and/or referral for many treatable mental health disorders. Those include depression, bipolar disorder, generalized anxiety disorder and post traumatic stress disorder.
The kit includes pocket reference cards, a clinician’s guide, patient screening forms and educational brochures. Because the pocket cards and clinician guide also come in text format, you can download them onto different types of PDAs.
The toolkits also include flyers, which can be placed in your office waiting room, to alert patients to the screening program.
For materials, visit the group's Web site. To access the description of toolkit contents, type in "pc" as your user name and "primary" as the password.
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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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