In the News for the Week of 5-3-05
- ACP/alliance adopt uniform set of pay-for-performance measures
Clinical news in the headlines
- Heart drug label to carry data on deaths
- Consumer drug ads often influence what doctors prescribe
Medical student news
- Applications due for primary care leadership training
- College now offers online dues payment
A broad alliance of national health care stakeholders, including ACP, last week approved a uniform set of clinically relevant performance measures. The measurement set could be incorporated in pay-for-performance programs throughout the country as early as next year.
The "starter set" of 26 measures was approved by the Ambulatory Care Quality Alliance (AQA), a collaboration of key national medical and quality organizations, health plans, purchasers, government agencies and accrediting organizations that began meeting last year.
Alliance members wanted to reach consensus on a measurement set to be used by the proliferating number of pay-for-performance programs. That consensus will help standardize performance measurement programs and reduce administrative burdens for physicians who participate in those programs.
ACP has played a key leadership role in AQA by serving on the alliance's steering committee since its inception. According to an open letter to College members posted on ACP Online, "ACP believes that the adoption of appropriate quality improvement and accountability measures, if done right, can result in better care for patients, increased patient and physician satisfaction, and potentially, improved reimbursement linked to quality." The May 3 letter was signed by College President C. Anderson Hedberg, FACP; Donna E. Sweet, FACP, Chair of the Board of Regents; and John Tooker, FACP, the College's Chief Executive Officer.
The approved set includes measures that target cancer screening, vaccinations, chronic care and prenatal care, as well as efficiency measures that address overuse and misuse. This initial set will rely primarily on readily-available administrative data to reduce physicians' burden of having to extract chart data.
In addition to reaching consensus on ambulatory performance measures, the AQA intends to develop both a multiyear strategy of rolling out additional measurement sets and a national model for aggregating and sharing data.
The letter to ACP members, which includes a link to the list of approved measures, is online.
For more information on AQA, see "Market forces now pushing pay-for-performance" in the May ACP Observer.
Clinical news in the headlines
The following articles appear in the May 3 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Studies find that exercise can help lower back pain. Two new studies help define the role of exercise in treating lower back pain.
A meta-analysis found that while exercise therapy has a small beneficial effect on pain and function in adults with chronic low back pain, it has no effect on pain that lasts less than six weeks. And a systematic review found that the two key features of successful exercise therapy for chronic low back pain are close supervision and an individually designed program.
Plant-based, low-fat diet improves cholesterol levels better than low-fat diet alone. A diet low in saturated fats and cholesterol and high in plant-based foods such as vegetables, fruits, beans and whole grains was more effective at lowering LDL cholesterol levels than a similar diet without the vegetables, a new study finds. In a four-week outpatient study, the two diets were identical in total fat, saturated fat, protein, carbohydrate and cholesterol—but one diet included many more plant-based foods.
An editorial pointed out that the study reinforces the fact that diet is a useful strategy for lowering cholesterol in an age of powerful drugs like statins.
Alendronate is not cost-effective therapy for women with osteopenia. A new study found that alendronate (Merck and Co.'s Fosamax) was not cost-effective in treating postmenopausal women with osteopenia or low bone mass. An editorial supported those findings, but also noted that older women with osteopenia or those with previous fractures are at higher risk for bone fractures than those with a risk factor for fractures. For this higher-risk group, the editorial stated, alendronate therapy may be "justified and cost-effective."
A new study sponsored by the National Cancer Institute (NCI) found that the cancer drug trastuzumab cuts in half the risk of recurrence for women with a certain type of breast cancer.
Two large trials involving more than 3,300 patients found that a combination of chemotherapy and trastuzumab worked significantly better than chemotherapy alone in patients with HER-2 positive invasive breast cancer, according to an April 25 NCI news release. Trastuzumab was found to slow or stop the growth of cancer cells that overexpress the HER-2 protein. According to the NCI, between 20% and 30% of breast cancers fall into this category.
Patients treated with chemotherapy and trastuzumab (Genentech's Herceptin) had a 52% decrease in recurrence compared with the chemotherapy-only group, the release said. Among those taking the combination therapy, only 15% had recurring cancer vs. 33% of those in the chemotherapy-only group, according to the April 26 New York Times.
The results suggest that early stage treatment could help keep more women free of cancer, said one expert interviewed by the New York Times. However, physicians were advised to wait for the full study to be published before changing therapies to find out details such as the severity of side effects, which include potential heart problems. The results will be presented later this month at the American Society of Clinical Oncology conference.
The NCI press release is online.
The New York Times is online.
The FDA has asked the manufacturer of the heart failure drug nesiritide to add information about mortality risk to its label after recent studies connected the drug with an increased risk of fatal kidney problems.
The new package insert reports that 5.3% of patients treated with nesiritide (Johnson & Johnson's Natrecor) died in clinical trials vs. a 4.3% mortality rate in control groups, according to the April 26 New York Times. The new label also states, however, that trials may have been too small to be statistically significant.
A study in the April 20 Journal of the American Medical Association (JAMA) found that nesiritide led to a 7.2% increased risk of death after 30 days of treatment, compared with 4% in patients on other treatments, the New York Times reported. A study in the March 2005 Circulation found that the drug was associated with a 40% to 50% greater risk of kidney problems.
Nesiritide has been used to treat more than 600,000 patients since it was approved in 2001, according to the New York Times. The drug, which alleviates shortness of breath, is used regularly by outpatient clinics to treat heart failure patients.
The New York Times is online.
The JAMA abstract is online.
A new study that used actors to portray patients found that physicians were five times more likely to write a prescription when patients asked for a drug by name.
In the study, standardized patients visited 152 general internists and family physicians in California and New York between May 2003 and May 2004. While one group of standardized patients simulated symptoms of depression, another group did not, reporting instead that they were experiencing stress and fatigue.
Among patients in the latter group who asked for a brand-name antidepressant, 55% received a prescription for the drug and 50% received a diagnosis of depression. (That compared to almost no patients being prescribed an antidepressant in the group reporting stress and fatigue who did not ask for the specific drug by name.) The study was published in the April 27 Journal of the American Medical Association (JAMA).
The authors concluded that while direct-to-consumer advertising may avert underuse of medications, as proponents claim, it also promotes overuse, according to the April 27 Washington Post. The authors suggested including company-funded educational messages in ads or banning ads for new drugs for three years after their release.
An accompanying editorial noted that, according to surveys, between 40% and 70% of physicians say that consumer drug ads encourage discussions of conditions and treatments between doctors and patients. However, the editorial added that 80% of physicians believe the ads encourage patients to ask for drugs they do not need.
The JAMA abstract is online.
The Washington Post is online.
Medical student news
Medical students interested in participating in the 2005 primary care leadership training program sponsored by the American Medical Student Association (AMSA) should file their application by Friday, May 6.
The weeklong program, being held July 25-29, is designed to teach medical students about important primary care issues and help them develop leadership skills. The theme of this year's program is "Serving the Underserved: Your Role," and will include discussions about the nation's community health centers. The program will be held at the University of Texas Health Science Center in Houston.
The AMSA is inviting 40 medical and dental students to participate in the program. The AMSA will pay for most meals, all materials and will reimburse each school or student up to $100 for travel and housing costs.
Medical schools can nominate up two students for the program. Applications need to be accompanied by a dean's certification and letter of recommendation and should be postmarked no later than Friday, May 6.
Watch for an ACP e-mail alert that should arrives shortly , saying that College dues are now due.
Members who want to pay dues online will be directed to the ACP Online, where their 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.
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 [firstname.lastname@example.org] or contact ACP Customer Services at 800-523-1546, ext. 2600 (Monday-Friday, 9 a.m.-5 p.m. ET).
The article in the ObserverWeekly 4-26-05 edition, "Northwestern residents win this year's Doctor's Dilemma," contained inaccuracies. Four teams—not two—played in the final Doctor's Dilemma round, which was held Saturday, April 16. And Steven E. Weinberger, FACP, the College's Senior Vice President for Medical Knowledge and Education, was incorrectly identified as the moderator of the final round. That moderator was Jeffrey Glassroth, MACP, Chair of the Annual Session 2005 Scientific Program Subcommittee.
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Copyright 2005 by the American College of Physicians.
A 66-year-old man is evaluated for vague abdominal pain of several months' duration and a 10-kg (22-lb) weight loss. He drinks alcohol socially but does not smoke. The patient is otherwise well, has good performance status, and takes no medications. Following a physical exam, lab studies, and a CT scan, what is the most appropriate initial management of this patient?
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