In the News for the Week of 12-6-05
Payment reform update
- Contact legislators now to avert payment cuts
- Council of Young Physicians calls for nominations
Clinical news in the headlines
- Annals highlights: Stroke risk after MI; tennis elbow and botulinum toxin
- Research highlights acetaminophen poisoning
- Study finds more elderly being hospitalized for infections
Avian flu update
- Stockpile of experimental vaccine set to grow
- Oversight office finds problems with drug card program
- Agency tells eyedrop maker to stop selling OTC products
- Physicians encouraged to enroll in Special Olympics directory
- College offers train-the-trainer program in geriatrics
- College comments on payment rules for power mobility devices
Payment reform update
ACP needs your help to ensure that Congress halts the Medicare payment cuts before the Congressional session ends this month. Ask your legislators to urge leaders of Congress to include at least two years of relief from Medicare cuts in any final conference agreement.
In Washington, a conference committee will be appointed in the next few days to work out differences related to physician payment updates between House and Senate budget reconciliation bills. Congress will likely work out those differences before it adjourns in mid-December.
The Senate bill would replace the scheduled 4.4% decrease in Medicare physician payments that would take effect Jan. 1 with a 1% increase. The Senate bill also contains pay-for-reporting provisions starting in 2007, with a 2% reduction in the conversion factor for physicians who do not report. The House bill calls for $50 billion less in federal spending for 2006 than the Senate bill, but it contains no Medicare payment provisions.
If conferees can reach a compromise, the final bill would go back to both the House and Senate for floor votes before the Congressional session ends. If approved by both bodies, the final bill would be sent to the president to sign.
It is far from certain that a budget bill will pass or that the payment cuts will be averted through inclusion in some other legislative vehicle such as being included in one of the two appropriations bills left to be approved.
To contact your senators and representatives, visit the Legislative Action Center for more information.
You can also access the latest issue of "The Capitol Key," the College's newsletter that focuses on advocacy efforts, for recent news on the fight to avert payment cuts.
The newsletter covers College leaders' testimony and meetings with influential lawmakers this fall and presents information on the "In Their Own Words" campaign. During the campaign, ACP representatives gathered first-hand accounts from physicians about how proposed Medicare cuts would affect their practices and gave those accounts to federal legislators.
The latest "Capitol Key" is online.
The College's Council of Young Physicians (CYP) is accepting nominations for one at-large representative and one representative each from the Western Region and the Southern Region. (See ACP Online for a listing of states in each region.)
The 11-member council is charged with providing an early-career physician's perspective to the College on socioeconomic issues related to medicine. The Chair of the Council has a seat on the Board of Regents, while the Chair-elect serves on the Board of Governors.
Representatives plan programs for young physicians at ACP's Annual Session, develop the Young Physicians section of ACP Online and help organize local young physicians’ councils in ACP chapters. The CYP's mission and goals are posted online.
Council terms begin May 1, 2006, and last for three years, with the council meeting twice a year. Candidates must be ACP Members or Fellows who have been out of medical school for no more than 16 years.
Interested members should self-nominate to their local ACP Governor and provide both a CV and a letter of interest that addresses this question: “What roles can the Council of Young Physicians play to create an environment within the College in which more young ACP members would actively participate at both the national and chapter levels?”
Nomination materials are due by Jan. 6, 2006, and must be submitted in electronic format to the nominee's local ACP Governor. Names and addresses of chapter Governors can be located on ACP Online.
For help contacting ACP Governors or for more information about the nominating process, e-mail Amy Allen Collins or call 800-523-1546, ext. 2692.
Clinical news in the headlines
The following articles appear in the Dec. 6 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Heart attack patients at high risk for subsequent stroke. A study of 2,160 people who had heart attacks found a high risk for stroke in the first month after the myocardial infarction. About 22.6 per 1,000 heart attack patients had a stroke within 30 days.
Heart attack patients who had a stroke were also almost three times more likely to die than those who did not have a stroke. Additional risk factors for stroke after heart attack were older age, a previous stroke and diabetes.
While researchers said the use of oral anticoagulation after acute myocardial infarction remains controversial, its use should be revisited. The strong association between stroke and death, they wrote, underscores the need for aggressive preventive approaches.
Botulinum toxin relieves pain of tennis elbow. In a small study, 60 people who had lateral epicondylitis for at least three months received one shot of botulinum toxin (BT) or inactive saline solution. The group receiving the botulinum toxin had less pain at one and three months.
Taking botulinum toxin made no difference in hand-grip strength, although it appeared to cause arm weakness and finger-function loss in a few cases. The botulinum toxin used in the study was clostridium botulinum type A neurotoxin complex (Dysport).
An editorial noted that physicians should reserve BT for traditional uses, such as treating involuntary movements, ticks, and disorders that feature prominent muscle spasms and abnormal postures.
Hospital-quality care at home is feasible and cost-effective. Sixty percent of patients who required hospitalization for one of four conditions chose to receive hospital-quality care at home, according to a new study. Patients who agreed to home treatment received similar quality of care, had fewer and shorter treatments, and generated fewer costs than those hospitalized.
An editorial held that the research affirmed the net benefits of hospital care at home, but that the study does not provide objective evidence to judge the medical or economic benefits of this type of care.
A new study has focused renewed attention on the risk of liver damage and unintentional poisoning as a result of taking too much acetaminophen.
Many patients are inadvertently taking high doses of acetaminophen because the drug is contained in so many over-the-counter (OTC) products as well as in prescription narcotics that contain acetaminophen, the Nov. 29 New York Times reported. About 200 prescription drugs contain acetaminophen plus an opiate, including hydroconebitartrate plus acetaminophen (Vicodin) and oxycodone hydrochloride plus acetaminophen (Percocet). The study appears in the December issue of Hepatology.
In the study, researchers tracked 662 patients who presented with acute liver failure at 23 U.S. transplant centers between 1998 and 2003. They linked 42% of those cases to acetaminophen overuse. During that five-year period, the annual percentage of acetaminophen-related acute liver failure rose from 28% to 51%. Suicide attempts accounted for 44% of those cases while most unintentional cases were among those taking multiple acetaminophen-containing products simultaneously or narcotic-containing compounds.
Susceptible patients also had concomitant depression, chronic pain, and alcohol or narcotic use, researchers said. The problem of taking too much of the drug via multiple OTC drugs was blamed in part on poor labeling that de-emphasizes acetaminophen risks, said the Nov. 29 New York Times.
Generally, adults can safely take four grams of acetaminophen over 24 hours, the New York Times reported, but taking up to eight grams can result in serious problems in people who have contracted a virus, taken other medication or consumed alcohol. Swallowing 12 to 15 grams in one dose could be fatal.
A Hepatology abstract is online.
The New York Times is online.
Government findings released last week show that hospitals had a substantial upturn in the number of elderly patients admitted for infectious diseases over the past decade.
Using data from the CDC's National Hospital Discharge Survey, researchers found that hospitalizations for infectious diseases increased by 13% among patients age 65 and older. The highest rate of hospitalizations was among those older than age 75. Lower respiratory tract infections were the most common reason for admittance, accounting for almost half the 21.4 million hospitalizations of the elderly between 1990 and 2002.
The most dramatic increases in the number of hospitalizations were recorded for infections of the heart (+242.9%); infections and inflammatory reactions (+134.3%); and post-operative infections (+81.7%). The biggest decrease (-39%) was for upper respiratory tract infections. The study appears in the Nov. 28 Archives of Internal Medicine.
The increase in hospitalizations among older adults is linked to the aging population, authors said. The study suggests that infection control measures should be focused on the most common causes of infectious disease mortality: lower respiratory tract infections; kidney, urinary tract and bladder infections; and septicemia.
The authors speculated that the drop in hospitalizations for upper respiratory tract infections could be due to better vaccine coverage for vaccine-preventable respiratory infections and because treatment for these patients has moved from the inpatient to outpatient setting.
The Archives of Internal Medicine abstract is online.
Avian flu update
The latest assessment of the nation’s avian flu vaccine supply shows that the government could have on hand almost 8 million doses of experimental avian flu vaccine by February 2006. Those 8 million doses, however, would be enough to vaccinate only 4 million people, with each person needing two shots over two months.
Two companies—Sanofi Pasteur and Chiron Corp.—are set to deliver the first batch of experimental vaccine doses by the end of this month, according to the Nov. 30 Washington Post. Because of the limited supplies, the government will likely restrict vaccine use to public safety personnel during a pandemic, the Washington Post reported. About a quarter of those vaccine supplies would go to a Pentagon-controlled stockpile.
Options being studied include diluting the vaccine to cover up to 120 million people, the article said. However, studies are still under way to see how effective diluted vaccine would be, and it is still unclear whether even full-strength vaccine would prevent illness in a pandemic.
The Washington Post is online.
A government investigation found widespread problems in Medicare’s drug discount card program, this year’s precursor to the Medicare drug benefit that will take effect in January 2006.
Problems included inaccurate information being sent to beneficiaries and improper card use. The study by the Government Accountability Office (GAO) noted that both the government and participating insurers had disseminated incomplete and inaccurate information, the Dec. 1 New York Times reported. Many pharmacies listed as participants on official Web sites, for example, did not accept beneficiaries’ cards.
An audit of drug cards revealed that 15 drug card sponsors had used Medicare money to pay for prohibited drugs such as barbiturates, resulting in $1.3 million in improper payments, the article said.
In addition, only 1.9 million out of a predicted 4.7 million beneficiaries who qualified for extra assistance signed up for the additional subsidy of up to $600 a year, the New York Times said. The GAO study found that the many choices offered to beneficiaries led to confusion and misconceptions, discouraging some people from enrolling.
CMS officials noted, however, that the number of problems and complaints has been low considering the size of the program and the fact that millions of prescriptions have been filled successfully.
A congressman from California who requested the study told the New York Times that the same problems identified in the study will undermine the new drug benefit unless they are corrected. Like the discount card program, he said, the new drug benefit presents seniors with many options, relies on private companies to negotiate savings and asks seniors to use a complicated Web site to choose a coverage option.
The New York Times is online.
The College has launched a new Web site devoted to Medicare Part D information for physicians. The site, which contains links to other resources, is online.
Also see "Getting yourself ready for Medicare Rx" in the October ACP Observer.
The FDA has asked the maker of popular over-the-counter (OTC) eyedrops and other products to stop manufacturing and distributing its drugs until problems at its production facility have been resolved.
California-based Molecular Biologics signed a consent degree last week to stop distributing eyedrops sold under the brand names Oxydrops, Bright Eyes, Bright Eyes II, Clarity Vision for Life, Visitein and Can-C, according to a Nov. 29 FDA news release. Several of the company’s OTC pain relievers, including Biogesic, Bio-Ice and Bio-Heat, were also included in the decree.
The FDA action was taken after Molecular Biologics failed to correct violations found during plant inspections, the FDA said. Those violations included poor manufacturing controls to ensure that eyedrops were sterile; distributing two unapproved drugs (Visitein and Clarity Vision for Life); and failing to provide adequate safety warnings on labels for its pain-relieving drugs.
The FDA recommended that consumers and health care providers dispose of the company's products. Adverse events connected with those products should be reported to the FDA’s MedWatch reporting program at 800-FDA-1088 or online.
The FDA news release is online.
ACP is urging members to sign up for the "Healthy Athletes" clinician directory, a new directory that will give prospective patients who have intellectual disabilities the names of providers willing to treat them. The directory is located on the Special Olympics Web site.
The directory asks for a minimum of physician information, including name and e-mail address. Listing your name in the directory does not guarantee patients' access to care, but only indicates that you are willing to provide care. Recent research shows that patients with intellectual disabilities have greater health care needs and more difficulties accessing health care services and physicians than the general public.
The directory, which was launched earlier this fall in partnership with the American Academy of Family Physicians, will be open to the public in early 2006.
More information and the enrollment form are online.
ACP’s Education and Career Development division is looking for general internists with a strong interest in geriatrics and peer education to participate in a unique train-the-trainer program.
Selected College members will attend a half-day facilitator training session Wednesday afternoon, April 5, 2006, in Philadelphia, prior to Annual Session 2006.
Participants will be trained to present special toolkit materials that provide an office-based approach to managing clinical problems in older adults. Trained facilitators can then present one or two one-hour geriatrics toolkit sessions per year in their communities at ACP chapter meetings or in other local settings. To date, more than 60 ACP members have been trained as facilitators.
Toolkit materials address topics such as falls, memory loss, pain management and urinary incontinence. The toolkits also contain case discussions, assessment tools, chart recording forms and patient education handouts. All the materials are evidence-based and designed to help primary care physicians manage the complex care of older patients in a time-effective way.
Candidates should be general internists with a strong interest in geriatrics and peer education. Applications will be accepted through Dec. 30, 2005, and those selected to participate will be notified by Feb. 1, 2006.
A limited number of $500 travel stipends are available to those who do not receive travel support to attend ACP’s Annual Session. Applicants should include a stipend request in their application letter, with an explanation of why support is requested. Stipends will be given on a first-come basis based on the receipt date of their application letter or e-mail.
Interested members should submit a current CV and a letter of interest summarizing their current work setting and responsibilities, their involvement and/or interest in geriatrics, and a brief explanation of why they are interested in participating in the facilitator training.
Application letters can be e-mailed or mailed to Lisa Rockey, Education and Career Development Coordinator, ACP, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.
ACP has asked the CMS to clarify the type of information physicians must submit to be reimbursed for prescribing power mobility devices.
In the Nov. 25 letter to CMS administrator Mark B. McClellan, FACP, the College said that some of the information the CMS is asking doctors to submit is readily available in physicians' offices. Submitting other required information, however—such as proving that the patient lives in a place where the device can operate—would create an "administrative burden" for physicians, the letter said.
The College also recommended that the CMS work with specialty organizations to create a form listing all the information the agency needs to reimburse physicians for prescribing power mobility devices.
ACP also asked the agency to clear up a data discrepancy. While the CMS estimates that physicians will annually prescribe 187,000 mobility devices, the agency's records indicate that Medicare paid for more than 8 million general wheelchair prescriptions in 2004. The College asked the CMS to explain how projected power mobility device figures relate to that claims data.
The letter is online.
For more information, see "Medicare ramps up coverage of power mobility devices" in the November ACP Observer.
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Copyright 2005 by the American College of Physicians.
A 62-year-old man is evaluated for declining exercise capacity over the past year. He was diagnosed with moderate COPD 3 years ago. His symptoms had previously been well controlled with tiotropium and as-needed albuterol. He has not had any hospitalizations. He is adherent to his medication regimen, and his inhaler technique is good. Following a physical exam and review of previously performed chest radiographs and pulmonary function testing, what is the most appropriate management?
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