In the News for the Week of 3-29-05
- College posts new end-of-life care resource site
- Annual Session program and handouts now available for PDAs
- College will offer online dues payment
- CMS will begin covering smoking cessation programs
Clinical news in the headlines
- Diabetes study finds women undertreated for heart risks
- Heart failure drug may impede kidney function
Health care disparities
- TB rate still high among minorities
- More adults willing to forgo physician choice to save money
ACP has developed a new Web page with resources to help physicians facilitate end-of-life care discussions with patients and family members.
The new page includes several College resources on end-of-life care, including the section of the ACP Ethics Manual that deals with end-of-life decision-making. That section provides members with guidance on assisting patients with end-of-life care issues, including withholding or withdrawing treatment.
The Web page also includes a link to a site that provides forms for health care proxies and living wills for each state. And the ACP site includes links to PEACE patient education brochures, a series that covers important end-of-life care issues, including working with surrogate decision-makers, dealing with pain at end of life and talking with patients at end of life. ACP members can order these brochures in bulk.
The ACP's end-of-life care resource page is online.
ACP members registered for Annual Session 2005 can now download the Annual Session Scientific Program schedule and course handouts for use on their PDAs.
The PDA-based Scientific Program schedule is available for both Palm and Pocket PC operating systems. It contains information about scientific sessions, special events and receptions, workshops at the Herbert S. Waxman Learning Center, exhibits and more. The schedule will also be available for download during the meeting in the main Exhibit Hall.
Course handouts for sessions are also available to registered Annual Session attendees in a restricted, password-protected area on ACP Online. The Acrobat PDF files may be downloaded and printed or converted for viewing on a PDA.
More information on Annual Session, to be held April 14-16 in San Francisco, is online.
This spring, ACP members will be able to use the ACP Online home page to pay their College dues online.
Watch for an e-mail alert that will be sent out in early May, saying that College dues are now due. Members who want to pay their dues online will be directed to the College home page, where they will be able to click on a "Pay Membership Dues" link. Members will have to provide their member ID number and a credit card number to pay via ACP Online.
All College members will still receive print bills for the upcoming year and can fax credit card information for payment, or pay by phone by calling Customer Service.
You can e-mail questions or contact ACP Customer Services at 800-523-1546, ext. 2600 (Monday-Friday, 9 a.m.-5 p.m. ET).
The CMS announced last week that it would begin covering smoking-cessation counseling for seniors with tobacco-related illnesses as part of its new prescription drug benefit, starting in 2006.
The new coverage will affect Medicare beneficiaries who have illnesses caused or aggravated by smoking—which account for the majority of Medicare spending—such as heart disease, cerebrovascular disease, lung diseases, weak bones, blood clots and cataracts, according to a March 22 CMS news release. Also covered are beneficiaries who take medications that are rendered less effective by smoking, including those for hypertension, blood clots and depression.
Public comment submitted before the ruling supported the new coverage, although some of those who commented pushed for coverage for all smokers, not just those with illnesses, the CMS release said. The ruling applies to smoking cessation treatments prescribed by a physician.
According to government figures, more than 9% of Americans age 65 and older smoke, leading to about 300,000 deaths a year from related diseases. About 10% of senior smokers quit each year, the agency said, while 1% of those relapse. On average, the CMS said, nonsmokers survive between 1.6 and 3.9 years longer than people who smoke.
The CMS news release is online.
Clinical news in the headlines
A new study concluded that physicians were less aggressive in treating risk factors for heart disease in women with diabetes than in men.
The study involved close to 3,900 diabetic patients—one-third of whom had heart disease—treated in five academic medical centers between 2000 and 2003. Researchers found that women were significantly less likely than men to receive recommended therapies for reducing heart disease risk, such as lipid-lowering drugs and aspirin. When treated, women were also less likely to reach recommended levels of LDL, blood pressure or HbA1C. The study appeared in the March issue of Diabetes Care.
Women with diabetes were 37% less likely than men to reach recommended levels of blood sugar, while women without heart disease were 16% less likely, according to the March 18 WebMD Medical News. Findings on treatment differences between men and women with diabetes included:
- Women were 18% less likely to be prescribed cholesterol-lowering therapy.
- Women were one-third less likely to be prescribed aspirin.
- Women with heart disease treated for high cholesterol were 20% less likely to reach recommended goals.
- Women with heart disease treated for hypertension were 25% less likely to reach recommended goals.
Those treatment disparities may suggest why cardiovascular death rates have risen among women with diabetes over the past three decades, researchers said, while rates have declined among men with diabetes and among the general population.
The Diabetes Care article is online.
WebMD Medical News is online.
A recent study found that nesiritide, used to treat congestive heart failure, increases the risk of renal malfunction in patients with acutely decompensated heart failure.
The meta-analysis included five trials that compared nesiritide (Johnson & Johnson's Natrecor) with either placebo or active control in 1,269 patients with congestive heart failure. Researchers found that nesiritide—when used at approved or lesser doses—significantly increased the risk of worsening renal function. The study appeared in the March 21 Circulation.
The study found that nesiritide led to a 40% to 50% greater risk of reduced kidney function compared with traditional therapies, according to the March 22 New York Times. That data suggest that the drug should be used only as a last resort, one of the study's authors told the New York Times, until a definitive study can be done.
A cardiologist who served on an FDA advisory panel told the New York Times that he voted against the drug's approval in 2001 because of concerns about excessive renal problems. The article noted that data used in the Circulation study had been submitted to the FDA before the drug's approval.
Johnson & Johnson officials interviewed by the New York Times said the analysis was flawed because it involved higher doses than are currently recommended. The drug, which is given intravenously, dilates blood vessels to prevent excess blood from collecting in the heart and lungs.
An editorial in Circulation noted that an FDA advisory panel approved a warning on the drug's package insert about the possibility of reduced renal function in some patients, the New York Times reported.
A Circulation abstract is online.
The New York Times is online.
Health care disparities
While outbreaks of tuberculosis (TB) in the United States have hit a record low, the disease still disproportionately affects immigrants and minorities.
There were 14,511 cases of TB—or almost 5 per 100,000 persons—reported in 2004 in the United States, the lowest rate since record keeping began in 1953, according to a March 17 CDC fact sheet. However, the rate of decline has slowed and the disease is concentrated in certain geographic regions that have high minority and immigrant populations.
In 2004, seven states—California, Florida, Georgia, Illinois, New Jersey, New York and Texas—accounted for more than half the reported cases nationwide, the CDC reported. In addition, the rate was 20 times higher among Asians than among whites and eight times greater among blacks and Hispanics than among whites.
The high rate among Asians reflects immigration patterns in countries where TB rates are very high, including China, India, Vietnam and the Philippines, the March 22 New York Times reported. Higher rates among Hispanics and blacks may be linked to high rates in Mexico, the article said, as well as the relatively high incidence of incarceration, homelessness and drug abuse among these groups.
Multi-drug resistant TB declined by 76.5% between 1993 and 2003, the most recent reporting year, the CDC said. The decline is likely due to steps taken after the epidemic of drug-resistant strains that took place in the 1980s, said the New York Times, which resulted in more timely, rigorous testing of TB patients for drug resistance.
The CDC said efforts are underway to improve overseas screening for immigrants and refugees and to test recent immigrants from countries with high rates of TB. The agency is also planning to fund demonstration projects to help African American communities deal with the disease.
The CDC fact sheet is online.
The New York Times is online.
Nearly 60% of patients participating in a national survey said they would rather save money on out-of-pocket medical costs than see the physician of their choice. All the respondents had employer-based medical coverage.
The survey found that 59% of the 20,500 adults queried in 2003 would opt for financial savings over physician choice. That pro-savings response rate was 4% higher than in a similar survey taken in 2001. (Earlier response rates had been stable since 1997.) The survey was conducted by the nonprofit Center for Studying Health System Change (HSC).
Survey results, which were released last week as an HSC issue brief, found that patients' desire to save was related to their income. According to an HSC press release, those in the lowest income percentiles were the most willing to give up provider choice. However, the proportion of those with higher incomes opting for less choice to save money increased from 50% to 54%.
The percentage of surveyed respondents who had chronic illnesses and were willing to limit access—regardless of income—also rose between the two study years, from 51% in 2001 to 56% in 2003.
The HSC issue brief is online.
The HSC press release 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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