In the News for the Week of 3-22-05
- ACP holds Hill briefing on physician payment system
- Wanted: internists for 5K charity run at Annual Session
- College issues quality recommendations to Congressional panel
- ACP Regent and Officer nominations due Aug. 1
- Senate rejects Medicaid cuts
- Federal study finds physicians lag in EMR adoption
- Match shows slight increase in internal medicine residents
- FDA approves drug for type 1 diabetes
- Eczema drugs spark safety concerns
- FDA panel recommends adult pertussis vaccine
Clinical news in the headlines
- Hospital leaders reject public reporting of errors
On March 18th, College officials held a briefing on Capitol Hill to present the steps needed to improve the dysfunctional physician payment system and improve the physician-patient relationship.
"Current Medicare payment policies favor episodic treatment of patients with acute illnesses," said College President Charles K. Francis, FACP, "rather than supporting the physician's roles as the patient advocate and coordinator of quality care of patients with chronic diseases."
Dr. Francis also pointed out that payment policies do not encourage use of electronic medical records, evidence-based clinical performance measures and other innovative models of practice innovations intended to improve the effectiveness of physicians' interactions with patients.
ACP called on Congress and the administration to create incentives for physician practice innovation and improvement. Such innovations would include use of electronic medical records and other health information technology to support evidence-based practice improvement; incorporation of clinical decision-support tools at the point of care; and new practice models to improve coordination of care of patients with chronic diseases.
ACP asked Congress to expand existing pilot programs testing new forms of physician payment. The existing programs do not encompass enough physician practices nor give physicians a big enough role in managing treatment for patients who are chronically ill.
More on comments at the briefing are online.
ACP is holding a 5K fun run and 3.5K walk at Annual Session 2005 in San Francisco to benefit a clinic for homeless patients staffed by University of California, San Francisco medical students.
The scenic race course—which is completely flat—will start in the famed Presidio, with participants headed toward the San Francisco skyline with the morning light rising over the hills across San Francisco Bay. The course then turns west toward the Golden Gate Bridge and will offer spectacular views of the Bridge, Bay and the San Francisco skyline.
Runners are invited to go five kilometers (just over three miles) while walkers will use a shorter, three and a half kilometer (2.2 miles) course along the same scenic route. Bus transportation to and from the course will be available for all participants.
Proceeds from both the run and walk will help support two clinics, which are organized by medical students who also staff a men's support group (a similar group is in development for women) and a smoking cessation program. First- and second-year medical and nursing students evaluate patients at the clinics and then present to a volunteer preceptor/faculty member.
The 5K event will take place Sat., April 16, from 6-7 a.m. (Shuttle bus transportation from ACP hotels begins at 5:15 a.m.) Internists attending Annual Session and guests are welcome to participate. The donation for the event is $25 per person.
More details are available online.
In written testimony recently submitted to a Congressional subcommittee, the College told lawmakers that quality performance measures that target the Medicare program must meet certain criteria—ncluding being based on evidence and having strong consensus support—to be effective.
ACP testimony was dated March 15 and addressed to the House of Representatives' Subcommittee on Health, Ways and Means Committee. That testimony said that quality performance measures must meet the following standards:
- Valid and reliable
- Relevant to physicians' clinical responsibilities
- Practical, without posing a significant burden on physicians
- Relate to clinical conditions prioritized to have the greatest impact
- Selected based on a strong consensus among stakeholder
In its comments, ACP also said that Congress should pass legislation to create a federal pilot program to test the efficacy of a physician-guided chronic care management program in small practices. Moreover, the College statement said that financial incentives should not be budget-neutral within Medicare, and program participation should be voluntary.
The statement also recommended that Congress enact laws to repair the dysfunctional payment system by replacing the sustainable growth rate formula with one that connects future payment increases to the increased costs of physician services. The College also recommended enacting a national health information incentive act to provide upfront funding mechanisms, including grants, refundable tax credits and revolving loans, to encourage physicians to invest in health information technology.
The testimony is online.
As part of the College's ongoing effort to include ACP members in the nominations process, the 2005-06 Nominations Committee solicits your recommendations to fill new Board of Regents positions that will become vacant in 2006.
The Nominations Committee is particularity interested in receiving nominations of women, ethnic minorities, international medical graduates, chairs of medicine and practicing physicians. The committee will give all nominations careful consideration.
When considering potential candidates, please keep in mind such qualifications as commitment to the College, dependability, leadership qualities and the ability to represent the College in diverse arenas. If you choose to nominate an individual, your letter of nomination should highlight these characteristics and should specify the reasons you feel your nominee is qualified for the position. Regent nominees must be ACP Masters or Fellows.
The nomination of an individual for first-term Regent must be submitted by a standard structured nominating proposal. A letter of nomination is required and should include:
- A brief description of the nominee's current activities.
- Special attributes the candidate would bring to the Board.
- Current and previous service in College-related activities.
- Service in organizations other than ACP (medical and non-medical).
A seconding letter must be submitted for each nomination. Without the appropriate material, the nomination will not be advanced for review.
Potential candidates for Regent are required to have one letter of nomination and one letter of support (the author of which will be identified by the nominator). Officer and Regent candidates must have new letters of nomination and support each year, as the old letters will be discarded. If candidates receive more than two letters (nomination and support), these additional letters will be discarded.
Please send your confidential nominations, no later than Aug. 1, 2005 to: Nominations Committee, attn. Pat Carter, ACP, 190 N. Independence Mall West, Philadelphia, PA 19106-1572. You can e-mail questions to Pat Carter at email@example.com, or call toll free 800-523-1546, ext 2815, or direct at 215-351-2815.
The Senate last week voted to reject proposed cuts to Medicaid, voting 52-48 to remove $14 billion in proposed Medicaid cuts from President Bush's proposed $2.57 trillion budget for 2006.
The vote came after vigorous advocacy from ACP and other medical organizations to maintain funding for the Medicaid program. In a letter dated Dec. 16, 2004, for instance, the College joined more than 20 other medical organizations, drug companies and health plans in asking the administration not to cut funding to the program, which helps provide care for 52 million Americans. Any cuts to or caps on the program, the letter said, would further erode an already "frail health care safety net."
The Senate version almost doubled President Bush's proposed tax cuts but rejected extensive cuts to entitlement programs, including Medicaid, according to the March 18 Washington Post.
The Senate instead passed an amendment to create a commission to explore possible changes to the program. Meanwhile, the House voted 218-214 to cut $69 billion in entitlement spending, including $20 billion from Medicaid. Those who supported the Senate Medicaid amendment, which was sponsored by Sen. Gordon Smith (R-Ore.), said states should be given the chance to make changes to the system before facing mandatory cuts set by Congress.
The Washington Post is online.
The College's letter cautioning against proposed cuts is online.
A recent government study found that while most physicians have moved forward on installing computerized billing, the majority has yet to adopt electronic medical records (EMRs).
Only 17% of physician offices have adopted EMRs, according to ambulatory medical care surveys conducted between 2001 and 2003 by the CDC, according to a March 15 CDC news release. That compares to about 31% of hospital emergency departments and 29% of outpatient departments. By contrast, electronic billing systems are used in 75% of physician practices.
About 8% of physicians surveyed used computerized physician order entry systems (CPOE), said the CDC release, with younger physicians more likely to use the systems than physicians over age 50. About 40% of hospital emergency departments and 18% of outpatient departments surveyed used automated drug dispensing systems—similar to vending machines—which are thought to reduce prescription and dispensing errors.
The CDC news release is online.
In related news, the Senate included a reserve fund to pay for health information technology (HIT) programs as part of its fiscal year 2006 budget resolution.
The reserve fund would allow Congress to spend money on health information technology and pay-for-performance programs without having to make "budget neutrality" offsets the same year. Instead, initial spending on such programs would not count against budget limits as long as they genreated sufficient savings to pay for themselves over a five-year period.
ACP supported the HIT reserve fund so that Congress could make an investment in health information technology without having to cut other health programs to pay for it. The Senate accepted ACP's recommendation to require that pay-for-performance programs funded under the reserve fund use "accepted evidence-based measures."
More from the College on adopting a national health information technology network is online.
A slightly higher number of U.S. medical school seniors chose an internal medicine residency program this year as opposed to last year, according to the National Resident Matching Program (NRMP) released last week.
According to a March 17 ACP press release, 3,104 U.S. medical school seniors opted for the three career-bound program tracks within internal medicine—categorical, primary care and med-peds—compared with 3,086 in 2004. This year, 86% of those choosing one of those three tracks chose the categorical track, which posted a 2% gain in the number of matching seniors over last year.
According to the press release,18 fewer U.S. seniors matched to the primary care track, a 9.6% drop over last year's Match figures. However, College officials said they were not concerned, because most primary care residencies take place in one of the country's 364 categorical programs, not in the 56 primary care programs. This year's lower primary care track figure does not necessarily mean that those residents will be less interested in a primary care career.
International medical graduates (IMGs) continue to represent a large percentage of the matched internal medicine slots. This year, IMGs accounted for 43% of categorical internal medicine slots, compared with 44% in the 2004 Match.
More information is available on the NRMP Web site.
The ACP press release is online.
The FDA last week approved a new diabetes drug for treating patients with type 1 and type 2 diabetes. The approval marks the first new therapy for type 1 diabetes since the approval of insulin several decades ago.
Pramlintide acetate, marketed as Symlin by San Diego-based Amylin Pharmaceuticals, works with insulin to control the flow of sugar into the bloodstream, according to a March 17 FDA talk paper. The drug was approved for use in patients with insulin-dependent type 1 diabetes, which affects about 4.5 million Americans, as well as for those with type 2 diabetes, which affects approximately 18 million.
In clinical trials, pramlintide acetate improved blood glucose control and weight loss in about 5,000 patients. That tighter control is desirable, the agency said, to reduce the long-term diabetes risks of blindness, kidney disease and vascular disease.
The drug's label will have a boxed warning about the risk of hypoglycemia, said the March 17 Los Angeles Times. In addition to that risk, the FDA noted the potential for medication errors when patients mix pramlintide acetate with insulin in the same syringe, as well as the potential for off-label use.The FDA said that pramlintide acetate should be used in combination with insulin to help lower blood sugar for three hours after eating.
Patients using the drug should follow up with their doctors often, the FDA paper said, and test their blood sugar levels before and after every meal and at bedtime. The drug should not be used in patients who have gastroparesis or are allergic to metacresol, D-mannitol, acetic acid or sodium acetate.
The FDA talk paper is online.
The Los Angeles Times is online.
The FDA recently issued advisories about two eczema drugs that have raised concerns about increased cancer risk.
The agency is adding a black box warning to the labels of pimecrolimus (Elidel) and tacrolimus (Protopic) due to a potential cancer risk, according to a March 10 FDA talk paper. After receiving reports of cancer in animals that were given the drug as well as in a small number of children and adults, the FDA asked the manufacturers to conduct further research to determine the extent of cancer risk in humans.
The FDA cautioned physicians that the two drugs are approved only for short-term and intermittent treatment of atopic dermatitis and should not be used continuously, said the talk paper. It also recommended using the minimum amount needed to control symptoms and not to prescribe the drugs to patients with weakened immune systems.
The FDA talk paper is online.
With the number of new cases of pertussis on the rise in the United States, an FDA advisory panel last week recommended approval of two new pertussis vaccines to be used in adolescents and adults.
The FDA's Vaccines and Related Biological Products Advisory Committee recommended approving two combined diphtheria, tetanus and acellular pertussis (dTpa) vaccines: GlaxoSmithKline's Boostrix for patients age 10-18 and Aventis Pasteur's Adacel for patients age 11-64, according to the March 15 WebMD Medical News. Most infants already receive pertussis shots in combination with tetanus and diphtheria vaccines, the article noted, but booster shots given to teens and adults do not include pertussis vaccine. That may be causing the rise in infections over the past several decades.
While pertussis is not usually harmful in adults, the article said, infected adults often spread the infection to children and infants in their households. According to the CDC, pertussis kills an average of 25 infants every year in the United States.
Possible side effects of the new vaccines include pain at the site of injection and mild fever, according to WebMD. The three-vaccine combination has never been given routinely to adolescents and adults in the United States, but Adacel is already in use in Canada and Germany.
WebMD Medical News is online.
For more information on pertussis, see "Rising pertussis rates spark new public health concern" in the March ACP Observer.
Clinical news in the headlines
Atorvastatin was effective in warding off heart disease—with no increase in recorded adverse events—in a recent trial involving patients with type 2 diabetes.
In the study, a group of 2,832 diabetic patients age 40 to 75 received either 10 mg daily of atorvastatin or placebo. Patients had one or more risk factors including hypertension, retinopathy, microalbuminuria or macroalbuminuria, or smoking, but no history of heart disease.
After four years, patients who took atorvastatin had a 5.8% rate of major cardiovascular events vs. a 9% rate for those on placebo. The study is abstracted in the March-April ACP Journal Club.
Patients taking atorvastatin in the study had a 31% reduction in LDL cholesterol, vs. no change for the placebo group, and a similar reduction in risk for heart attacks and strokes. These results, the Journal Club reviewer said, indicate that diabetic patients would benefit from statin therapy regardless of their baseline lipid levels.
While the new data suggest that one drug at a fixed dose is effective in preventing heart disease, they do not address the risks or benefits of further LDL reduction with increased doses or drug combinations, said the reviewer. However, the study provides direct evidence of the substantial benefit and low risk of statin therapy for primary prevention of heart disease.
ACP Journal Club is online.
A new and controversial report published last week found that the nation's current obesity epidemic will curtail life expectancy gains made over the past 200 years, primarily because of the steady increase in the number of obese children.
Past gains in life expectancy were due to better survival rates among the young, the report said, while future gains will occur from extending the lives of patients as they age. According to the report authors, obesity and its complications—such as diabetes and hypertension—could level off or cause a drop in life expectancy of between two-five years in the United States by 2050. The report was published in the March 17 New England Journal of Medicine.
An accompanying editorial as well as researchers quoted in the March 17 New York Times, however, said the report is too pessimistic. The editorial noted that reversing the obesity trend is not out of the question because the U.S. population is capable of changing its unhealthy habits, as it has done with smoking.
Much of the controversy surrounds what is included in life expectancy forecasts. The New York Times reported, for instance, that other life expectancy forecasts predict the trend toward extended life expectancy to continue, even if the obesity problem continues to worsen. That's because those forecasts take future medical advances into account.
The report's authors estimate that life expectancy at birth in this country would be higher for virtually everyone if obesity were not a factor. Black males would gain the most, from .30 to 1.08 years. They note that two-thirds of adults in this country are obese or overweight, and that children and minorities have shown the largest increases in body weight index.
The NEJM abstract is online.
The New York Times article is online.
Survey results published last week found that most hospital executives oppose public disclosure of medical errors. Survey responses indicated that executives feared public reporting and disclosure would discourage hospital personnel from reporting mistakes.
The survey, taken from 2002-2003, targeted the chief executives and chief operating officers of 203 hospitals in six states, some of which had mandatory disclosure or public reporting laws. The majority (63%) of respondents said a mandatory reporting system with public disclosure would discourage error reporting, while 79% said such a system would encourage lawsuits and 73% said it would not improve patient safety.
Executives from states where error reporting is made public were less likely than others to say they would report to the state errors that resulted in moderate injuries. Only between 3%-7% of respondents already in states with the public disclosure laws said they would report the least severe cases, compared with 20%-34% in states where errors are kept confidential. The survey results appeared in the March 16 Journal of the American Medical Association (JAMA).
Researchers noted that states with mandatory reporting systems rarely require that affected patients be notified of reported errors. They also noted that executives in mandatory reporting, public disclosure states with mandatory reporting or public disclosure were less worried than others about lawsuits and were more willing to have hospital names made public. According to the authors, this indicated that acceptance of public error reporting among hospital executives may increase over time.
The JAMA abstract is 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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