In the News for the Week of 4-19-05
Special Annual Session issue
- New College initiative aims to reshape diabetes care
- Governors tackle flawed payment system
- Setting the record straight: ACP and No Free Lunch
- College works to help labs destroy dangerous vaccine
- ACP's Recruit-a-Colleague winner announced
- Helping your patients die with dignity
- Avoiding the potential risk of drug interactions
- HIV/AIDS: becoming a chronic disease under internists' care
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
At Annual Session last week, ACP leaders announced a new and massive initiative to improve diabetes care—the single largest project the College has undertaken in collaboration with a pharmaceutical company.
With an unrestricted educational grant provided by Novo Nordisk, the three-year ACP-ACP Foundation Diabetes Initiative is designed to disseminate components of high-quality diabetes care to physicians and patients throughout the country, as well as to recognize physician practices that verifiably improve diabetes care.
A key component of the new project is to promote a multidisciplinary, team approach to diabetes care that "isn't divided among different turfs," said outgoing College President Charles K. Francis, FACP. While physicians will continue to play a key role, this initiative is designed to change the practice patterns of subspecialists, physician assistants, nurse educators and patients themselves."
Vincenza Snow, FACP, the College's Director of Clinical Programs and the Clinical Director of the new initiative, outlined new ACP products and services that the grant will support over the next three years. These include:
A new MSKAP program for diabetes self-assessment designed to be used by all members of a diabetes health care team, including nurse educators and physician assistants.
A CD-ROM to help physicians either design their own patient registry database for diabetic patients or teach physicians what to look for in commercial patient registry software products.
Clinical Skills modules on diabetes that will be available to College members and introduced at future Annual Sessions and chapter meetings.
A patient safety module on diabetes.
A recognition program to acknowledge those physicians and medical groups that improve their care of diabetic patients.
Patient educational materials that promote self-management will be available in English and Spanish.
Several of the new services and programs should help physicians with pay-for-performance and quality improvement programs related to diabetes, Dr. Snow said. In addition, she added, the College will use grant funds to enhance the existing diabetes content of College products, including PIER. An ACP "portal" (Web site) will bring together all of the College's extensive diabetes information in one electronic format.
The issue of the dysfunctional payment system topped the Board of Governors meeting agenda last week as Governors, Regents and invited speakers met to discuss the flawed reimbursement system and ways to reform it.
"The dysfunctional payment system is oppressive, Byzantine and discriminatory," said Cecil B. Wilson, MACP, who led the discussion from the physician's perspective. Dr. Wilson, who has a solo practice in Winter Park, Fla., said he has more than 1,300 insurer addresses in his computer and that three-to-four month payment delays are common whenever a patient switches plans.
Patients often expect their physicians to know the details of each plan, he added, while insurers expect doctors to be 100% accurate in their filings or face payment delays. Fear of denied or delayed payments, he added, encourages physicians to adopt tactics such as downcoding to avoid denials.
Dr. Wilson listed other problems of the flawed payment system from the physician's point of view, including administrative hassles and poor communication between physicians and insurers.
The Governors discussed the idea of the primary care physician's office as the patient's "medical home," with the internist acting as care coordinator and being reimbursed accordingly.
Several Governors also suggested changes to the insurance industry, including standardizing benefits across plans and mandating individual coverage. By simplifying communication among insurers, doctors and patients, the Governors said, additional savings would be realized. Governors also pointed out that pay-for-performance programs could hold some answers by rewarding doctors for efficiently using technology and for following evidence-based guidelines.
The Governors also approved a number of resolutions related to reimbursement to be considered by the Board of Regents. Those included:
Funding pay-for-performance rewards with new dollars created from cost savings, separate from inflationary updates in physician fee schedules.
Increasing compensation for cognitive services by exploring changes to the current payment system. Suggested changes included changing the Medicare formula of tying fee increases to the sustainable growth rate and revising the fee-for-service-based payment methodology, which is based on acute episodic care.
Working with the AMA to advocate for an increase in physician fees for visits to Medicare beneficiaries in nursing homes.
In an ongoing dialogue about physicians' interactions with the pharmaceutical industry, College leaders last week met with Robert Goodman, MD, the New York internist who founded No Free Lunch. No Free Lunch is a nonprofit group committed to not accepting promotional gifts, drug samples or hospitality from drug companies.
Last week's meeting grew out of the College's decision, made in January after careful consideration, to not grant a request from No Free Lunch to exhibit at this year's Annual Session.
According to John A. Mitas II, FACP, the College's Chief Operating Officer, ACP's decision was made in accordance with College policy regarding media representation and exhibitors. In 2001, Dr. Mitas said, a physician claiming to represent No Free Lunch escorted investigative reporters who had a hidden camera into the Annual Session Exhibit Hall—in violation of College policy. ACP policy prohibits the use of cameras, as well as interference with exhibitors, in the Exhibit Hall.
"The College welcomes dialogue and representation of different points of view about issues of concern to the medical profession," said Dr. Mitas. "But we also have a responsibility to our members to ensure that all exhibitors agree to terms of engagement on how they will operate on the exhibit floor."
Members of the College's Ethics and Human Rights Committee were among those who presented a session entitled "Ethical Challenges: Physician-Industry Relations—Maintaining an Appropriate Balance" at Annual Session.
"Physicians and their specialty organizations need to have an ongoing assessment of their relationships with industry—and of the potential impact of those relationships on the independence of clinical judgment," said Regent William E. Golden, FACP, outgoing Chair of the Ethics and Human Rights Committee, who moderated that session.
Dr. Goodman has agreed to meet with ACP's Ethics and Human Rights Committee at their next meeting, at the invitation of Dr. Golden.
ACP's Medical Laboratory Evaluation (MLE) program last week announced that it is working with the CDC to make sure that its 173 laboratories destroy recently-received vaccine containing a potentially dangerous strain of the influenza virus.
All of those labs have notified ACP MLE that they had disposed or destroyed the substance according to CDC guidelines. ACP MLE staff is working to contact all remaining labs by phone or fax.
The specimens, from Meridian Bioscience Inc. of Cincinnati, were manufactured for proficiency testing. They included a strain of the influenza virus called H2N2, which had not been in circulation since 1967. As a result, they could pose a health risk to those born after 1968. That "Asian Flu" strain caused the deaths of more than 1 million people in 1957.
According to the CDC, at least 4,000 labs in 18 countries received the virus in quality-control test kits.
An ACP MLE press release is online.
A transcript of an April 13 CDC briefing on the potentially dangerous vaccine strain is online.
James Leonardo, ACP Member, from Cooperstown, N.Y., has won a free trip to the 2006 Annual Session in Philadelphia. Dr. Leonardo's name was drawn last week in an Annual Session raffle held to encourage internists to recruit new College members.
The grand prize includes registration, airfare and four days of hotel accommodations. ACP members were entered in the drawing if they successfully recruited new members.
More information on the College's Recruit-a-Colleague program is online.
In the wake of the Terri Shiavo "right to die" case, end-of-life ethical questions are on many physicians' minds. How should physicians handle family wishes that run counter to their best medical judgment? What role should physicians play in final end-of-life decisions, particularly if family members have differing wishes, and should physicians keep patients alive through extraordinary interventions?
In a session on death and dignity presented at Annual Session, Steven A. Levy, FACP, associate clinical professor at Lake Erie College of Osteopathic Medicine in Erie, Pa., said that physicians' effective communication skills and empathy can minimize conflict in end-of-life care. Learning what the family is truly concerned about can also dissipate anger and ease confusion.
According to Dr. Levy, there has been a shift in how physicians think about dying patients: Instead of focusing on interventions, they are now focused on real treatment goals. Physicians should be consensus builders, he said, as they lay out the available options and work with family members to arrive at informed decisions.
Dr. Levy's advice: "Never ask someone, 'What do you want us to do?' or 'Do you want us to do everything?' " Most families will say 'yes' out of guilt without thinking about the implications, he said. Instead, tell families that you will do everything possible "that will help."
"Palliative care is the most important thing we can do for a dying person," Dr. Levy said. "But too often it is dismissed as not doing enough."
As the number of drugs increases, so do the number of drug interactions, escalating the risk of medical errors and complicating patient treatment.
And according to David Flockhart, ACP Member, PhD, physicians usually don't get extensive training on drug interactions in medical school. At Annual Session, Dr. Flockhart told a standing-room only session that physicians who want to understand the benefits and dangers of drug interactions need to know about the human cytochrome P450 system, better known as CYP.
Dr. Flockhart, chief of clinical pharmacology at Indiana University in Indianapolis, said that the CYP system acts as a barrier against external chemicals. These enzymes line the gastrointestinal track and are heavily concentrated in the liver.
Many of the drugs that internists prescribe—tricyclic antidepressants, beta- and calcium channel blockers, all of the HIV protease inhibitors, even ibuprofen—go through this system. Medications and substances that inhibit this system include ketoconazole, itraconazole, erythromycin—even grapefruit juice.
When patients ingest some inhibitors, like grapefruit juice, it can take the CYP system nearly a week to recover—and the half-life of a drug doesn't matter. "You can't use the half-life of a drug," he said, "to predict its potency of inhibition."
That's why it's so important for internists to know what their patients are taking, including herbal medications. Dr. Flockhart's Web site details just how different medications and substances interact.
A leading HIV/AIDS expert last week predicted that in the not-so-distant future, the care of patients living for decades with the disease will once again become the purview of physicians specializing in chronic care: general internists.
"In the West, HIV is becoming a chronic disease like diabetes," Merle A. Sande, MACP, told attendees at an Annual Session presentation on HIV issues for internists. And just like tending to diabetics, he said, managing patients on long-term HIV antiretroviral treatment will require physicians to figure out ways to improve compliance and understand therapeutic complications.
Studies of HIV patients in the United States have found that patients take only 60%-80% of their prescribed medications, while evidence shows that patients need to take nearly all of them to derive the benefits, said Dr. Sande, a College Regent.
Adherence will likely improve—as it has in parts of Africa—when clinicians eventually reduce the number of drugs patients need to take every day. Another important part of providing chronic care is managing the complications of therapy, particularly because the drugs now keeping patients alive for decades can be "extremely toxic," he said.
Clinical news in the headlines
The following articles appear in the April 19 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Primary care is endangered in the United States. The country may be headed for boutique medicine for those who can afford it, primary care in large integrated systems for those who have health insurance, and "a poorly compensated, disorganized group of safety net providers," according to an editorial that introduces a special supplement on primary care.
Vaccination plus antibiotics best strategy after anthrax attack. A new study to determine the best strategy to handle a large-scale anthrax attack on a mid-sized U.S. city suggested that post-attack vaccination plus antibiotic therapy is the most effective and least expensive strategy. An editorial found the analysis limited because it fails to consider factors such as social panic, disintegration of the medical infrastructure, evacuation and decontamination costs, and the current federal decision to stock only 75 million doses of anthrax vaccine nationwide.
Metformin and lifestyle changes slow metabolic syndrome. A large randomized controlled trial assigned participants to take metformin; enact lifestyle changes, including intensive weight loss diet and exercise; or placebo. An analysis of the data found that for participants who did not have metabolic syndrome at the beginning of the study, both drug and lifestyle interventions reduced the development of the syndrome.
Among those who already had metabolic syndrome, both lifestyle change and drug therapy resulted in increased likelihood that the syndrome would disappear compared to placebo. In both cases, the benefit of changed diet and exercise was greater than the benefit of drug therapy.
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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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