In the News for the Week of 12-13-05
Payment reform update
- Fate of 2006 physician payments still unclear
- College outlines payment reform options
- College, others, object to student loan cuts
Clinical news in the headlines
- ACP Journal Club: antibiotics and urinary tract infections
- One-third of colon cancer patients do not receive chemotherapy
- Infliximab effective against ulcerative colitis
- State offices seeking help with drug benefit counseling
- Agency claims company’s eyewash products are contaminated
- Minorities often not invited to join clinical trials, study finds
- New Web site can help boost women's heart health
- PIER PDA now transitioning to new enhanced program
Masters and awardees
- New ACP Masters and awardees announced for 2006
Payment reform update
Although Congress returned to Washington last week after an extended Thanksgiving break, no action has yet been taken to avert physician pay cuts scheduled to take effect Jan. 1. It is also unclear whether Congress will act to avert cuts before it adjourns sometime this month.
While the House last week completed action on several tax bills, it did not vote on fiscal year 2006 appropriations for several departments, including the HHS. The House and Senate also remain far apart on a separate budget reconciliation bill to trim spending on entitlement programs, including Medicare and Medicaid. Budget reconciliation between the different House and Senate bills is the best hope for halting the scheduled 4.4% reduction in Medicare physician fees.
Although Congressional leaders publicly say that they expect to complete action on appropriations and budget reconciliation, ongoing negotiations may not produce an appropriations or budget reconciliation package that can pass both the House and the Senate.
ACP continues to strongly advocate for stable physician payments for a minimum of two years and for implementing phased-in quality improvement programs under Medicare. The College has also expressed opposition to proposed House reductions in funding for vital Title VII programs, the Agency for Healthcare Research and Quality, the NIH and the CDC.
Last week, ACP Key Contacts were activated to urge legislators to support Senate Title VII funding and to oppose the 69% reduction that would occur if House Title VII funding levels are accepted.
To encourage legislators to act now on physician payment reform and health care program funding, visit ACP's Legislative Action Center.
ACP has outlined payment reform options to key federal officials to help avert the 4.4% physician payment cuts slated to begin next month. College recommendations to stabilize Medicare payments and lead to long-term Medicare payment reform were sent in a Dec. 7 letter signed by College President C. Anderson Hedberg, FACP.
Dr. Hedberg wrote that Congress should stabilize physician payments for at least two years by not allowing the sustainable growth rate (SGR) cuts to take effect. The letter, as well as a list of payment reform options, was sent to key Senate and House leaders, as well as to the CMS administrator.
Dr. Hedberg also wrote that beginning in 2007, Medicare should provide higher payments to physicians who voluntarily report on quality measures. Among other recommendations, ACP included the following:
physicians who choose not to voluntarily report quality data should not receive negative payment updates;
the CMS should work with the Ambulatory Care Quality Alliance—a consortium of medical groups, health plans and large employers, of which ACP is a leading member—to establish key voluntary reporting measures; and
the CMS should expand and continue its reporting program in 2008 to include pay for performance only if the SGR has been replaced. Without long-term payment reform, the letter pointed out, the government will not have a pool of dollars to provide a bonus pool to physicians for weighted performance data and will not enable physicians to share in systemwide savings.
The letter is online.
ACP payment reform options are online.
The College has joined several dozen national medical provider and academic groups to oppose a proposal that would effectively eliminate federal funding for student loan programs under Title VII and Title VIII.
ACP signed onto a Dec. 5 letter that objected to administration plans to rescind funding for several student loan programs, including the health professions student loan program, the primary care loan program and the loans for disadvantaged students program. These programs provide long-term, low-interest loans for economically disadvantaged and underrepresented minority students to pursue a health care degree.
The proposed cuts, which could be added to several pending bills dealing with federal spending, would effectively end federal support for these loan programs next year. Such rescissions would renege on a national commitment to educate health care professionals for needy communities, the letter said, and "threaten the infrastructure of our nation's healthcare infrastructure."
Other groups that signed the letter included the American Academy of Pediatrics and the Society for General Internal Medicine.
The letter is online.
Clinical news in the headlines
A recent study found that antibiotics were effective in treating women with symptoms of urinary tract infections, even those who tested negative on a urine test.
The randomized controlled trial included 59 women ages 16 to 50 who had a history of dysuria and a negative dipstick test for both leukocytes and nitrates. The women received either 300 mg of trimethoprim for three days or placebo. After the third day, 24% of women taking antibiotics reported dysuria compared with 74% of those on placebo. At seven days, only 10% of the antibiotic group reported symptoms vs. 41% in the placebo group.
The study is abstracted in the January-February ACP Journal Club and posted early online.
Physicians should be cautious of the results, said Journal Club reviewer Leonard Leibovici, MD, of the Rabin Medical Center in Petah-Tiqva, Israel. Offering antibiotics to a large proportion of symptomatic women regardless of their urine test results creates a significant risk of side effects and drug resistance.
The study, while scientifically sound, may not have achieved a representative sample of participants, said Dr. Leibovici. Only about 20% of eligible women were recruited and selection may have been biased toward women with prior infections, because they would be more likely to volunteer to take antibiotics.
Further studies are needed to confirm these findings, both the authors and reviewer said. Those studies should focus on the overall response to antibiotics as well as the value of laboratory tests in predicting response.
Peer ratings for this review: general internal medicine, primary care, family practice: 7/7 stars
ACP Journal Club is online.
Although chemotherapy advances over the past 15 years have prolonged survival for many colon cancer patients, a recent study found that women and the elderly are less likely to receive chemotherapy treatment. The study also found that the most widely used chemotherapy drugs for colon cancer were less effective in blacks.
Researchers analyzed almost 86,000 cases from the National Cancer Data Base—maintained by the American Cancer Society and the American College of Surgeons—between 1990 and 2002, when the most common chemotherapy drugs for colon cancer were 5-fluorouracil and leucovorin. They found that the frequency of adjuvant treatment increased from 39% in 1991 to 64% in 2002 and that survival increased from 8% to 16%, compared with surgery alone. The study appears in the Dec. 7 Journal of the American Medical Association (JAMA).
However, despite established evidence that chemotherapy improves survival, one-third of the patients never received adjuvant treatment and certain subgroups were less likely to be treated. Those subgroups included patients over age 80, patients with invasive tumors and women. While potential risks associated with treating elderly patients or those with advanced cancers might explain the first two findings, an accompanying editorial pointed out, there was no obvious reason for why women were treated less frequently than men.
The study also found that blacks benefited less than whites from chemotherapy treatment, although the editorial recommended caution in interpreting this result. While it is possible, the editorial said, that blacks received less treatment because their white blood cell count was lower than that of whites, leading to a higher incidence of neutropenia, it is also possible—as some studies have suggested—that blacks are less likely to receive chemotherapy than whites.
According to the authors, future studies should focus on whether newer drugs, such as irinotecan and oxaliplatin, are more effective in blacks and in patients with advanced tumors.
A recent study found that a drug traditionally used to treat Crohn’s disease was effective in treating patients with ulcerative colitis.
In two randomized double blinded trials involving more than 725 patients with moderate to severe ulcerative colitis, patients received either placebo or infliximab (5 mg or 10 mg per kilogram of body weight) intravenously over 22 weeks in one trial and 46 weeks in another. In both trials, patients who received infliximab had a significantly better response—such as decreased rectal bleeding—than those on placebo. The study appeared in the Dec. 8 New England Journal of Medicine (NEJM).
Ulcerative colitis is characterized by mucosal ulceration, rectal bleeding, diarrhea and abdominal pain. It is typically treated with aminosalicylates, corticosteroids and immunosuppressants, said the authors, although some patients do not respond to treatment and some develop corticosteroid dependence.
Authors noted that patients in the study were already receiving conventional therapy at baseline. Treatment with infliximab allowed some patients to discontinue corticosteroid therapy, which is associated with considerable morbidity.
Because there were no major differences between the 5 mg and 10 mg groups, the authors concluded that 5 mg should be the preferred initial dose. An induction regimen of three doses of infliximab followed by maintenance infusions every eight weeks, the authors said, can achieve clinical response and remission, mucosal healing and corticosteroid-sparing effects.
The NEJM abstract is online.
State and local officials are struggling to meet seniors' demand for information and counseling on Medicare’s new prescription drug benefit.
The demand is hindering enrollment in the program, which is slated to begin Jan. 1, according to the Dec. 8 USA Today. Beneficiaries who do not sign up by May 15 could face enrollment cost penalties.
In a recent meeting with federal officials, a Delaware official quoted in the article pointed out that his state has only four staff members to advise 120,000 seniors and that about 60 calls per day are going unanswered. Federal officials responded that they have already increased funding for state counseling programs over the past two years from $12 million to almost $32 million and have recruited churches and other outside groups to help with counseling.
Other states overwhelmed with calls include Oregon, which has four counselors and 200 volunteers, and Missouri, with eight staff members and 200 volunteers. Both states said staff is two weeks behind in answering calls. In Michigan, four state staff members fielded 13,000 phone calls in October, USA Today reported, compared to a total of 43,000 phone calls for all of 2004.
USA Today is online.
Patients can get additional information about the state house insurance assistance program online or by calling 800-677-1116.
Patients can also get additional information at Medicare’s Web site or by calling 800-MEDICARE.
And the College has launched a Medicare Part D-dedicated Web site as part of ACP's Practice Management Center site.
The FDA last week warned consumers not to use eyewash products made by Tedco Inc. due to contamination that could cause serious infections.
The warning applies to Tedco’s Miracle II Neutralizer products, according to the Dec. 7 Washington Post. The products, which are sold in drug stores and on the Internet, are marketed as eyewash and treatment for cataracts and pink eye.
According to a Dec. 6 FDA news release, the Neutralizer products are bacterially contaminated and could pose a serious risk of infection, particularly in children, the elderly and people with weakened immune systems. Tedco also markets the products for unapproved uses, the FDA said, including treatment of AIDS, cancer, Crohn’s disease, diabetes, earache and gout, among other conditions.
Tedco has refused to voluntarily withdraw the products from the market, the FDA release said. Health care providers and consumers are urged to dispose of the products and report adverse events to MedWatch at 800-FDA-1088 or online.
The FDA news release is online.
The Washington Post is online.
A newly released NIH study suggests that poor access—not distrust of the medical establishment—is the primary reason for minorities’ low participation in clinical trials.
NIH data show that minorities volunteered for medical studies just as frequently as whites but were less likely to be invited to participate, according to the Dec. 6 Washington Post. Results were based on 20 public health studies that reported consent rates by race and ethnicity of more than 70,000 individuals. The study, posted early online, will appear in the February 2006 edition of PLoS Medicine, a peer-reviewed open access journal from the Public Library of Science.
Past studies have reported that minorities distrust medical researchers as a result of the Depression-era federally sponsored Tuskegee Institute study in Tuskegee, Ala., in which nearly 400 low-income black men were denied available treatment for advanced syphilis for 40 years, the Washington Post said. The NIH study is the first to test whether that distrust explained minorities’ low profile in trials.
The 20 studies, which spanned more than 20 years, covered a wide range of diseases, including substance abuse, schizophrenia, HIV infection, cancer and cardiac diseases, and recurrent throat infection, researchers said. While there were only slight differences in the consent rate among ethnic groups, they said, researchers noted substantial differences in the numbers from each group invited to participate.
In one study that began in the 1970s involving surgery for angina pectoris, for instance, researchers found that out of 2,095 people invited to participate, only 30—or 1.4%—were from minority groups. By 1980, minorities comprised 17% of the U.S. population, with angina pectoris more prevalent among blacks and Hispanics than among whites. Minorities in that study had agreed to participate at a higher rate than whites (43.4% vs. 37.1%).
Researchers said that clinical trial directors should focus on making studies more accessible to minority patients. Strategies to improve access include making sure minorities are informed of trials and invited to enroll; choosing sites that are accessible to minorities; and providing help with child care, travel expenses and language issues.
The PLoS article is online.
The Washington Post is online.
As part of a new NIH national awareness campaign on heart disease in women, physicians can now access a new Web site with continuing medical education (CME) resources on cardiovascular health issues for women.
Called "Heart Truth," the campaign and Web site are designed to raise awareness of female heart disease among physicians and patients. In addition to free CME modules for physicians and nurses, the Web site also includes patient education and public awareness tools.
Physicians can use the site to access interactive case-based modules on the following:
- risk assessment and primary prevention in low-risk women,
- metabolic syndrome and coronary heart disease (CHD) in women,
- secondary CHD prevention in women, and
- heart disease diagnosis in women.
Other curricula materials on the site include slide sets about cardiovascular disease in women. Downloadable patient education resources include guides to behavioral change, facts about hypertension, brochures on dietary approaches to better heart health, as well as fact sheets and health assessment tools.
More information is online.
ACP and Skyscape Inc. have announced an agreement to transition all PIER PDA subscribers to a new Skyscape mobile program that combines PIER with other features. Skyscape is the leading provider of interactive mobile medical references, with a registered user base of 450,000 practitioners and more than 300 resources covering 30+ medical specialties.
Under the agreement, all current subscribers to ACP's PIER PDA can upgrade for a free one-year subscription to a special Skyscape bundle that includes PIER and the dosing companion from the American Society of Health-System Pharmacists (ASHP).
Skyscape’s version of PIER includes PIER's rationale and evidence sections plus hundreds of images and supplemental tables not previously available. In addition, Skyscape is offering special savings to all other ACP Members on PIER and on hundreds of other physician references for mobile devices.
More information about the special offers available to ACP members is available on the Skyscape Web site.
Masters and awardees
The College's Board of Regents has approved the following individuals and institutions to receive College awards and Masterships at the 2006 Annual Session.
Those who wrote supporting letters for nominees will receive additional notification, announcing the winners and inviting supporters to submit new nominations.
If you would like to personally congratulate any of the new awardees or Masters, please contact Meghann Williams, Administrative Representative for Awards, by e-mail or by calling 800-523-1546, ext. 2714; or Martha Cornog, Manager of Membership Services, by e-mail, or at 800-523-1546, ext. 2696.
The following are new awardees:
John Phillips Memorial Award
Myron L. Weisfeldt, FACP, Ruxton, Md.
James D. Bruce Memorial Award
Nancy A. Rigotti, FACP, Lincoln, Mass.
Alfred Stengel Memorial Award
Whitney W. Addington, MACP, Chicago
American College of Physicians Award
Peter C. Agre, MD, Baltimore
Edward R. Loveland Memorial Award
Project HOPE, Millwood, Va.
William C. Menninger Memorial Award
Glenn Treisman, MD, PhD, Baltimore
Distinguished Teacher Award
Shahbudin H. Rahimtoola, MACP, Los Angeles
The Richard and Hinda Rosenthal Foundation Award #1
Susan H. Hou, FACP, River Forest, Ill.
The Richard and Hinda Rosenthal Foundation Award #2
John I. Gallin, MD, Potomac, Md. (contingent on approval from the National Institutes of Health)
Ralph O. Claypoole Sr. Memorial Award
Warren W. Furey, MACP, Chicago
Nicholas E. Davies Memorial Scholar Award
2006: Edmund D. Pellegrino, MACP, Bethesda, Md.
2007: Charles S. Bryan, MACP, Columbia, S.C.
Outstanding Volunteer Clinical Teacher Award
Marcel Tuchman, FACP, New York
Joseph F. Boyle Award
Mark R. Warner, Governor of Virginia, Richmond, Va.
Oscar E. Edwards Memorial Award
David W. Gregory, FACP, Nashville, Tenn.
Alvan R. Feinstein Memorial Award
The Feinstein Award will not be given in 2006.
Walter J. McDonald Award for Young Physicians
Susan Thompson Hingle, FACP, Springfield, Ill.
Joseph E. Johnson Leadership Award
Lisa L. Ellis, ACP Associate Member, Sioux Falls, S. D.
Herbert S. Waxman Award for Outstanding Medical Student Educator
Barry J. Wu, FACP, New Haven, Conn.
ACP will also honor the following new Masters at Annual Session
Masood Akhtar, FACP, Milwaukee
Ronnie J. Anderson, FACP, Dallas
Stephen C. Beuttel, FACP, Winston-Salem, N. C.
Keith M. Brownsberger, FACP, Anchorage
Robert A. Clark, FACP, San Antonio
N. Thomas Connally, FACP, Arlington, Va.
Jerry C. Daniels, FACP, Galveston, Texas
William F. Denny, FACP, Tucson, Ariz.
Edgar R. Dickson, FACP, Rochester, Minn.
R. Philip Eaton, FACP, Albuquerque
Theodore C. Eickhoff, FACP, Denver
Earl R. Ensrud, FACP, Champaign, Ill.
John F. Farrington, FACP, Boulder, Colo.
Mark Feldman, FACP, Dallas
Anthony S. Felsovanyi, FACP, Menlo Park, Calif.
Jose A. Filos-Diaz, FACP, Panama, Panama
Robert L. Frye, FACP, Rochester, Minn.
Manuel García de los Rios, FACP, Santiago, Chile
Abraham Garcia-Kutzbach, FACP, Guatemala City, Guatemala
Mario Geller, MACP, Rio de Janeiro, Brazil*
Hossein Gharib, FACP, Rochester, Minn.
Robert S. Gibson, FACP, Charlottesville, Va.
Ben D. Hall, FACP, Johnson City, Tenn.
R. Brian Haynes, FACP, Hamilton, Ontario, Canada
C. Anderson Hedberg, FACP, Winnetka, Ill.
William L. Henrich, MACP, Baltimore*
Jerome M. Hershman, FACP, Los Angeles
Richard J. Kahn, FACP, Rockport, Maine
Emmet B. Keeffe, FACP, Palo Alto, Calif.
Gerald R. Kerby, FACP, Kansas City, Kan.
Rashida A. Khakoo, FACP, Morgantown, W. Va.
Richard B. Kohler, FACP, Indianapolis
Mack A. Land, FACP, Memphis
Eugene P. Libre, FACP, Kensington, Md.
Geraldo Medeiros-Neto, FACP, Sao Paulo, Brazil
Glenn Molyneaux, FACP, Santa Rosa, Calif.
Owen St. C. Morgan, FACP, Kingston, Jamaica
Thomas J. Nasca, FACP, Philadelphia
Nancy H. Nielsen, FACP, Orchard Park, N.Y.
James G. Nuckolls, FACP, Galax, Va.
Joseph T. Painter, FACP, Houston
Jose Ramirez-Rivera, FACP, San Juan, Puerto Rico
E. Chester Ridgway, MACP, Denver*
Louis L. Sanders, FACP, Little Rock, Ark.
D. William Schlott, FACP, Baltimore
Emil Skamene, FACP, Montreal
Alexander M. Sloan, FACP, Severna Park, Md.
W. James Stackhouse, FACP, Goldsboro, N.C.
David E. Steward, FACP, Springfield, Ill.
Donna E. Sweet, FACP, Wichita, Kan.
Esther A. Torres, FACP, San Juan, Puerto Rico
Roger H. Unger, FACP, Dallas
Alan G. Wasserman, FACP, Washington
Christopher S. Wilcox, FACP, Washington
Neal S. Young, FACP, Washington
*Received Mastership last year but could not attend Convocation
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A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?
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