In the News for the Week of 3-1-05
Clinical news in the headlines
- AAMC calls for increase in MD grads
Health care disparities
- Report finds racial, ethnic and income gaps in quality
- Some pharma, biotech jobs shifting overseas
- Government share of health spending expected to soar
- Educational conference to focus on correctional health care
Clinical news in the headlines
The following articles appear in the March 1 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
New studies find that diabetes prevention is cost-effective. Two new studies looked at issues in preventing type 2 diabetes mellitus.
In the first study, new results from a large trial of heart disease prevention in men found that positive lifestyle changes lowered the risk of developing diabetes among nonsmokers, but did not affect smokers' risk.
Researchers followed a subgroup of 11,827 men whose glucose levels were normal at the beginning of the study, assigning participants to a program to change diet, stop smoking and increase physical activity, or to usual care.
About the same percentage of both groups (11.5% of the intervention group vs. 10.8% of the usual care group) developed diabetes over a six-year follow-up period. However, among nonsmokers, those in the intervention program were less likely to develop diabetes than those receiving usual care.
In the second study, a computer simulation used data from the Diabetes Prevention Program and other published reports to determine the cost-effectiveness of program interventions, which included an intensive diet modification and exercise program, taking the diabetes drug metformin or placebo.
Researchers found that both the diet-exercise program and metformin therapy reduced patients' risk of developing diabetes. The diet-exercise program would cost about $8,800 a year, while metformin therapy would cost about $29,000 per year of healthy life saved. The authors noted that both are within the range of typical spending for health care treatments. The diet-exercise program had a favorable cost-effectiveness profile for all adult ages, while metformin therapy was not cost-effective after age 65.
In light of the studies' evidence, an editorial calls for community-wide diabetes prevention programs.
Hepatitis B vaccination protects for 15 years, not 10. Researchers examined more than 840 Alaskan natives who had been vaccinated against hepatitis B virus 15 years earlier. They found that 84% had protective antibodies, while only three participants had become infected with the virus during the 10-15 year follow-up period. Previous research suggested that the vaccine protects against infection for only up to 10 years. The article is online.
New data released last week from the Women's Health Initiative suggest that menopausal hormone replacement therapy increases the risk of urinary incontinence among postmenopausal women.
The study included more than 27,000 postmenopausal women enrolled between 1993 and 1998 who had urinary incontinence symptoms either at baseline or after one year of treatment. Women received either 0.625 mg of estrogen plus 2.5 mg of progestin, 0.625 mg of estrogen alone or placebo.
Researchers found that estrogen, alone or with progestin, increased the incidence of urinary incontinence at one year among women who did not have symptoms at baseline, while it worsened symptoms among women who were already incontinent. The study appeared in the Feb. 23 Journal of the American Medical Association (JAMA).
Researchers noted that oral estrogen plus progestin or estrogen alone have long been prescribed to alleviate postmenopausal symptoms, including urinary incontinence. In the past, clinicians have thought that because hormonal therapy improves symptoms of atrophic vaginitis, it might also improve incontinence. In addition, the higher rate of incontinence among middle-aged women encouraged an association between estrogen deficiency and both menopause and incontinence.
The authors pointed out that this is the first study to conclude that estrogen alone worsens incontinence.
The JAMA article is online.
To combat an expected physician shortage, the Association of American Medical Colleges (AAMC) last week recommended that American medical schools boost enrollment 15% by 2015.
According to a Feb. 22 AAMC news release, that increase would result in 2,500 more physicians graduating every year. The AAMC recommended targeting increases to the fastest-growing regions in the nation and also removing the restriction now in effect on the number of residency and fellowship positions funded by Medicare.
Of 118 allopathic schools that responded to a 2004 AAMC survey, 31% indicated definite or likely plans to boost first-year enrollment over the next several years, while another 20% said they were considering increasing enrollment over the next six years. The AAMC attributed the looming workforce shortage to several factors, including the growth in the U.S. population, increasing demand from aging Baby Boomers, expected physician retirements and younger doctors working shorter hours.
The AAMC news release is online.
Health care disparities
A new government report on health care quality found that while overall quality has improved somewhat, minorities still receive lower levels of care than white patients.
According to the 2004 National Healthcare Quality Report released last week by the Agency for Healthcare Research and Quality (AHRQ), overall quality improved by about 3% since 2003. It is the AHRQ's second annual quality report.
According to a Feb. 22 AHRQ press release, improvements included:
A 37% decrease between 2002-03 in the percentage of nursing home patients reporting moderate or severe pain.
A 34% decrease between 1994-2001 in hospital admission rates for uncontrolled diabetes.
A 34% decrease between 1996-2000 in the percentage of elderly patients given potentially inappropriate medications.
However, an accompanying report on disparities found that blacks experienced poorer quality of care than whites for about two-thirds of quality measures and about 40% of access measures, while Hispanics received lower quality care for half of quality measures and 90% of access measures.
In addition, low-income patients received lower quality of care on about 60% of the quality measures and 80% of the access measures than those with higher incomes, the news release reported. Better care for low-income patients was found in the 3,600 federally supported health centers, the release said, adding that the government plans to fund 40 new health centers in FY 2006.
In its 2003 position paper on racial and ethnic health care disparities, ACP identified six areas that need to be addressed to reduce inequities in health care. Those areas are health insurance coverage, patient care, provider issues, delivery systems, societal concerns and research.
The AHRQ news release with a link to the full reports is online.
The College's position paper is online.
An article released last week looked at trends in medicine—particularly pharmaceutical and biotech research and manufacturing—to move positions to other countries. The article appeared in the Feb. 24 New York Times.
Several American pharmaceutical companies are already doing drug screening and clinical trials in Asia, Latin America and Eastern Europe, the article noted.
While the number of jobs displaced from the United States to other countries is small so far, the article pointed out that more pharmaceutical manufacturing may move abroad. India already has an extensive generic pharmaceutical manufacturing sector.
Driving the trend is the fact that many Chinese and Indian scientists educated in the United States are returning to their home country, the article said.
Factors working to keep research and manufacturing positions here include the high profitability of the pharmaceutical industry and the fact that many drug and biotech companies want to stay close to American universities, which receive funding from the National Institutes of Health.
The New York Times is online.
According to a new government study released last week, government spending will account for almost half of the country's health care expenditures by 2014. The study also found that total health care spending in the United States will double over the next 10 years.
Overall health spending will increase from $1.8 trillion in 2004 to $3.6 trillion in 2014, making up 18.7% of the 2014 economy vs. 15.4% last year, according to the Feb. 24 New York Times. The new estimates, published online Feb. 24 in Health Affairs, said government spending will increase to 49% of all U.S. health care spending by 2014. The study was supervised by CMS officials.
The rise in the government's spending share is being driven in part by the new Medicare drug benefit, which will shift a large portion of spending from the private to the public sector, the New York Times reported. Medicare's portion of spending on prescription drugs will go from 2% now ($4.5 billion) to 28% next year ($69.9 billion), while spending by private insurers and individuals is expected to drop from $170 billion now to $147 billion next year.
Patients who go from having no insurance to receiving the Medicare drug benefit will save on out-of-pocket drug costs, according to the New York Times. However some retirees could see a cost increase even with the Medicare benefit because some employers may drop retiree coverage. A group of health care providers and suppliers, meanwhile, noted that the report did not take into account projected savings estimates from such factors as lower death rates and fewer inpatient days.
The Health Affairs article is online.
The New York Times is online.
The National Commission on Correctional Health Care is inviting ACP members to its spring educational conference, to be held April 9-12 in Las Vegas. ACP is a member of the commission's board of directors.
The itinerary has 40 workshop presentations, seminars and plenary sessions. Topics include reducing variability in chronic disease management; anticipating future workforce needs; legal and mental health issues; and basic preparedness and response to bioterrorism in correctional settings.
More information is online.
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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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