In the News for the Week of 2-1-05
Annals of Internal Medicine
- Deadline looms for "Internists as Artists" program entries
- Annual Session 2005 to feature immunization quality improvement demo
- College seeking workshop proposals for Annual Session 2006
- Coming soon: online College dues payment
- ACP issues health information technology recommendations
- High-tech pact may spur building of national health network
- Survey: more practices using EHRs
The business of medicine
- Rural physicians have higher 'real' income than urban clinicians
Access to care
- Large employer group will offer options to uninsured workers
Clinical news in the headlines
- New strategies for controlling Type 1 diabetes
- New quality report names the nation's top performing hospitals
Annals of Internal Medicine
The College's flagship publication, Annals of Internal Medicine, is now offering its Web readers continuing medical education activities and credits related to Annals articles.
Two new questions will appear in each Web issue of Annals, which is published twice a month. (Both questions will relate to one specific article.) Physicians will earn up to one category 1 credit for each two-question course. Annals plans to publish 24 different CME courses related to articles this year.
To get credit for completing questions, readers need to be a current or former Annals subscriber. Physicians with current licenses in the U.S., Canada and Mexico can take the course, even if they live in other countries.
Once you've completed a two-question course, your quiz score will be displayed and the correct answers will be highlighted. Annals will provide a personalized online CME summary page that will be updated to reflect the hours earned. That page will contain a link for a printable version of the official course certificate, which you can submit.
More information about Annals CME courses is online.
A direct link to the current CME questions is online.
The following articles appear in the Feb. 1 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Task force recommends abdominal aortic aneurysm screening for male smokers age 65-75. The U.S. Preventive Services Task Force (USPSTF) is recommending a one-time ultrasound examination to screen for abdominal aortic aneurysm in former and current male smokers age 65-75. This is the first time the USPSTF has recommended screening for abdominal aortic aneurysm.
New evidence shows that screening and surgery to repair large abdominal aortic aneurysms in men reduces the number of deaths from ruptured aneurysms. According to estimates, between 59% and 83% of patients with such aneurysms die before reaching a hospital and having surgery. More…
Study: One COX-2 inhibitor increases heart attack risk even in patients with no myocardial infarctions. In this early release study, the health records of 113,927 elderly people with no history of heart attack were examined for the relationship between use of nonsteroidal anti-inflammatory drugs (NSAIDs) and heart attack risk. Researchers studied aspirin, naproxen and meloxicam, as well as the COX-2 inhibitors rofecoxib and celecoxib.
They found that patients using rofecoxib had an increased risk for myocardial infarction and that the risk was greater at higher doses. They also found that using aspirin offset the heart risk associated with low rofecoxib doses, but not higher doses. Researchers found no evidence of increased heart risk with other NSAIDs.
This study adds to the growing evidence that rofecoxib increases heart disease risk. It also contributes to the now inconsistent body of evidence about heart risks of celecoxib: Some studies have shown increased risk, while others have not. The article, which has been posted early online, will be published in the April 5 print edition. More…
Many pneumonia patients can be treated successfully at home. A study of 203 patients with community-acquired pneumonia and low risk for dying found that about 80% of both those treated at home and those treated in the hospital improved without side effects, complications or the need to change antibiotics. At the same time, home-treated patients were more satisfied with their overall care.
An editorial notes that inpatient care is expensive and that outpatient care has some advantages in encouraging recovery. The editorial claims that study findings, if confirmed, should stimulate emergency departments to systematize their approach to managing community-acquired pneumonia. More…
Entries for the ACP's national "Internists as Artists" program at Annual Session 2005 are now being accepted. All entry application forms must be submitted by Feb. 11.
Designed to showcase physicians' talents in the visual arts, the "Internists as Artists" exhibit will be located in the Exhibit Hall of the Moscone Convention Center in San Francisco during Annual Session. Submissions can include painting, sculpture, photography, mixed media, woodworking, jewelry, crafts and ceramics.
Members interested in submitting entries must complete an application form and send it along with either a photograph or an electronic image of their artwork. (Member artists may submit a maximum of two entries.) Entries will judged by program jury members, and each piece must be completely display-ready when it is submitted for consideration in the exhibit.
"Internists as Artists" is modeled on an Evergreen Award winning event established by ACP's Virginia Chapter.
Completed application forms and electronic or photographic images should be sent to: Helen Canavan, ACP Internists as Artists Program, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. Ms. Canavan can also be reached via e-mail or by calling 800-523-1546, ext. 2663.
Physicians attending this year's Annual Session are invited to a hands-on demonstration of "Put ACASA Into Practice!," ACP's immunization quality improvement program. The demonstration will be held Friday, April 15, in San Francisco.
"Put ACASA Into Practice!" is a team-oriented, practice-based program to help physicians and staff improve their delivery of influenza and pneumococcal immunization services. The College project uses the Adult Clinical Assessment Software Application (ACASA), a free database program developed by the CDC to assess a practice's immunization levels, produce reports to help pinpoint service delivery problems and improve the quality of patient care.
The College program is designed to measure and report on the impact of ACASA on practice immunization services over three years. "Put ACASA Into Practice!" participants learn how to create a registry of influenza and pneumococcal immunization rates in patients overall and in high-risk patients. That initial sample serves as baseline data.
Program training also incorporates systems learning that examines ways to tailor specific practice environments to boost long-term immunization rates.
ACASA program training is also available at ACP headquarters in Philadelphia. More information is online.
More information and a free download of ACASA software are online.
More information about "Put ACASA Into Practice!" at Annual Session is online under the Computers in Practice section.
The ACP Clinical Skills Subcommittee is now accepting proposals for interactive skills workshops to be presented at Annual Session 2006. Applications with proposals must be received by April 1, 2005.
The subcommittee welcomes all proposals, but places a high priority on interactive workshops designed to help physicians acquire or improve skills in physical examination, communication or specific procedures. The subcommittee is most interested in workshops that rely on proven teaching techniques or new and innovative teaching strategies designed to change physician behavior.
Proposals can be for 60-, 90- and 120-minute presentations or one- or two-day sessions. If resources permit, ACP will help course directors get needed equipment and evaluate workshop participants.
Workshop faculty receive travel expenses, a per diem for hotel and food, meeting registration and a small honorarium. The subcommittee will make its final selection of workshop proposals in May.
Annual Session 2006 will be held in Philadelphia April 6-8, 2006. Proposal applications are online and must be received by April 1, 2005.
In a few months, ACP members will be able to pay their ACP dues online. Watch for an e-mail alert this spring on the new feature, with a link to your dues bill. You will then be able to use a secure connection to pay by credit card, or print out a bill to pay by check or through your office accounting.
The new online service will be available only to members who have a current e-mail address on record with ACP. You can update or add an e-mail address online. To change your e-mail address, log in with your ACP ID number and password. You will then be directed to a site where you can use the "My Account" link to add or update your e-mail address.
All members will still receive print bills for the upcoming year.
You can e-mail your questions, or contact ACP Customer Service at 800-523-1546, ext. 2600 (Monday-Friday, 9 a.m.-5 p.m. ET).
The College recently submitted a comprehensive set of recommendations to the federal government on how a national health information technology network should be developed and financed.
Among its recommendations for developing a health information technology infrastructure, the College outlined current barriers to a national interoperable network. Those barriers include:
System disparities. Rural and inner-city physicians, as well as small primary care practices nationwide, will need more support and assistance than large multispecialty groups or systems with multiple hospitals.
Reimbursement policies. Reimbursement policies must be changed so physicians will not continue to be penalized for investing and training in information technology. At the same time, the burden of technology implementation cannot become an unfunded mandate for physicians, and Medicare and other insurers must find mechanisms for reimbursing physicians for e-mail and telephone consultations, quality improvement programs and care coordination.
Legal concerns. Providers must be able to exchange patient information across state lines, and barriers that now exist to electronic information exchange—such as Stark and Drug Enforcement Agency regulations—need to be removed.
The College also recommended that a national public authority be established to mandate technological standards to be used in information networks; that state governments take an active role in developing and maintaining such networks; and that physicians and patients prominently govern how information is gathered and shared.
The letter is online.
I.B.M. and Microsoft were among a group of eight technology giants that announced an agreement last week to accept open, nonproprietary software standards to help build a national health information network.
The move is a major step toward creating an interoperable network, in which physicians, other providers and insurers could share patient information across one network, according to the Jan. 26 New York Times.
While the College has recommended that a public authority be created to establish technology standards (see previous news item), the companies urged HHS to create a new nonprofit to be called the National Health Technology Standards Corp. HHS would appoint members to that company who would determine national software standards.
The report also recommended that the government provide seed funding and incentives to help physicians and hospitals purchase equipment to participate in the network, the New York Times reported.
Besides I.B.M. and Microsoft, consortium members include Intel, Oracle, Accenture, Cisco, Hewlett-Packard and Computer Sciences. The companies—which have created an alliance called the Interoperability Consortium—made the announcement in a report to the national health information coordinator, one of hundreds of reports submitted with recommendations on how to build a national health information network.
The New York Times is online.
Physicians are increasingly replacing paper patient records with electronic health records, according to results released last week of an ongoing member study conducted by the Medical Group Management Association (MGMA).
While 69% of responding practices are still using paper charts, 20% of respondents said they've converted to an electronic health record (EHR) system—up from only 9% of surveyed members a few years ago, according to the Jan. 25 Modern Physician. Practices surveyed had three or more physicians, and the survey defined an EHR as a computer-accessible system that keeps medical and demographic information in a database.
Among respondents, 15% had a fully implemented EHR system, while 8% had systems that combined physician notes that were electronically stored with scanned paper charts. The survey also found that 40% of respondents planned to implement an EHR system within two years, Modern Physician said. The ongoing survey is being funded by the Agency for Healthcare Research and Quality, which is seeking more detailed data from 16,000 groups.
Modern Physician is online.
The business of medicine
Survey results released last week found that primary care physicians who practice in rural areas earn significantly more than their urban counterparts when their respective incomes are adjusted for cost of living.
The 2001 survey of 12,000 physicians, conducted by the Center for Studying Health System Change (HSC), was adjusted for inflation to 2003 levels. It found that the average actual income of rural physicians, including specialists, was lower than for urban clinicians: $204,000 vs. $218,000.
But when adjusted for the cost of living, rural physicians fared much better. According to the Jan. 26 Modern Physician, the buying power of primary care physicians, for instance, was found to be 30% higher: $189,000 for primary care physicians in rural areas, compared to $145,000 for urban physicians.
The survey also found that primary care physicians make up 54% of the rural physician workforce, compared to 38% in cities, and that rural primary care physicians worked an average of 10% more—five hours a week—than primary care physicians in urban areas.
The HSC report is online.
Modern Physician is online.
Access to care
Sixty large employers came together last week to announce that they will offer low-cost health insurance options to their uninsured workers and early retirees.
The program will begin in September, last for at least two years and could attract 3 million people—about 7% of the nation's 45 million uninsured, according to the Jan. 27 New York Times. The program's employer sponsors, which include General Electric, I.B.M., McDonald's and Sears, invited more companies to participate, noting that new insurance options may head off some state legislative proposals that might mandate coverage of uninsured workers.
The companies will not financially contribute to uninsured workers' premiums. But by joining together, the employers create a large enough pool of workers to make it worthwhile for insurers to offer lower rates, the New York Times reported. Participating insurers include UnitedHealth Group and Humana, while Cigna will offer a plan in Arizona.
Premiums would range from $5 a month for discount cards applied to doctor, pharmacy and hospital charges, to $300 a month for high-deductible plans covering major medical expenses. Besides helping part-time and temporary workers afford benefits, the plan could help older employees maintain coverage if they stop working full-time.
The New York Times is online.
Clinical news in the headlines
Study results released last week found that controlling risk factors for heart disease is just as important for patients with Type 1 diabetes as for other diabetics to ward off nerve damage.
Type 1 diabetics have long been advised that controlling blood sugar is their only route to preventing nerve damage, according to the Jan. 27 Associated Press. However, the study by British researchers suggests that controlling weight, hypertension, smoking and other cardiovascular risk factors is just as important. The study appeared in the Jan. 27 New England Journal of Medicine (NEJM).
In the seven-year study, more than 23% of the 1,172 patients who began the study without nerve damage developed neuropathy. After adjusting for glycosylated hemoglobin value and the duration of diabetes, researchers found that the incidence of neuropathy was significantly associated with modifiable risk factors including high cholesterol and triglycerides, excessive weight, hypertension and smoking.
Patients with hypertension were twice as likely to develop neuropathy, the Associated Press reported. The authors noted that the results suggest the need for clinical trials on the effectiveness of antihypertensive drugs to slow the development of neuropathy.
The NEJM abstract is online.
The Associated Press is online.
A newly released study of nearly 5,000 U.S. hospitals named those hospitals that performed in the top 5% on 28 different diagnoses and procedures for Medicare patients. According to the report, Medicare patients treated in a hospital in that top tier had better survival rates ranging from 12%-20% for those diagnoses and procedures.
The report compared risk-adjusted data from Medicare patient records from 2001-03, and identified 229 hospitals nationwide that posted the best clinical quality results. Survival rates for patients who received heart bypass surgery in hospitals in that top tier were 15% higher than patients treated in hospitals with average quality scores, while survival rates for patients with community-acquired pneumonia in top hospitals were almost 20% better.
The report was the third annual hospital quality report published by HealthGrades, a company that grades providers and posts results on the Internet. According to a Jan. 24 HealthGrades news release, close to 53,000 patient lives would have been saved between 2001-03 if all hospitals performed as well on clinical quality as those hospitals in the top 5%.
Links to both the HealthGrades' report and press release are online.
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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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