In the News for the Week of 6-14-05
- Government seeks bidders on plans to create national health network
Clinical news in the headlines
- A court ruling paves the way for generic competition for OxyContin
- Public reporting may encourage cardiologists to refuse high-risk cases
- Projected 2006 HMO rate increases are lowest in five years
- ACP issues position paper on redesigning Medicaid
- College supports new outreach bill for uninsured children
- New bill calls for uniform HIT standards
The federal government last week announced plans to spend $86.5 million this year on health information technology, including awarding contracts to private-sector companies to help create a national electronic network.
The Department of Health and Human Services sent out requests for proposals last week, according to a June 6 HHS news release. It also announced the formation of the American Health Information Community (AHIC), a private-public collaboration that will guide the national transition to electronic health records.
With the RFPs, the department is looking for companies and nonprofit organizations who can help solve technical issues, such as privacy, security and data-sharing standards, reported the June 7 New York Times. The government funding is "seed money" said an official quoted in the article. Companies seeking the contracts likely will join in collaborative bids.
The AHIC, chartered for two years, will be chaired by HHS Secretary Michael O. Leavitt, who will appoint up to 17 members, said the HHS release. The commission's charter can be renewed for up to five years, at which time it is expected to transition into a private-sector community initiative that would set additional standards and certifications, and provide long-term guidance on HIT issues.
The idea is to give the market structure, said the HHS release, so that the medical community and vendors can move forward with new products and processes.
The HHS news release is online.
The New York Times is online.
A study published last week reported that—contrary to expectations—intensive treatment with statins did not halt calcific aortic stenosis progression.
In the trial, 77 patients with calcific aortic stenosis received 80 mg of atorvastatin while 78 patients received placebo. After a median follow-up of two years, LDL cholesterol levels had fallen significantly in the atorvastatin group compared with the placebo group, but disease progression was similar in both groups. The study appeared in the June 9 New England Journal of Medicine.
The results were surprising in light of previous studies linking atherosclerosis with hypercholesterolemia, the authors said. One possible explanation for the new results is that decreasing the lipid pool may be less important to the progression of aortic stenosis than it is to reducing plaque rupture in patients with coronary heart disease.
Calcific aortic stenosis is the most common form of valvular heart disease, affecting 3% of adults over age 75, said the authors. The disease is long and progressive, and patients may go decades without knowing that the aortic valve is narrowing. But it eventually narrows quickly, necessitating a valve replacement for the patient. While statins appear to be ineffective in halting the disease, the authors said, more studies are needed on whether the drugs may confer secondary benefits, such as preventing myocardial infarctions.
The New England Journal of Medicine abstract is online.
Picotamide worked better than aspirin in preventing death in patients with type 2 diabetes and peripheral arterial disease, according to a recently published study.
In the two-year trial, 1,209 patients ages 40-75 with type 2 diabetes were given either 600 mg of picotamide twice daily or 320 mg of aspirin, with the aspirin dose taken in the morning and a placebo at night. The picotamide group had a lower death rate than the aspirin group (2.8% vs. 5.1%), but there was no significant difference between the two groups for non-fatal cardiovascular events. The study is abstracted in the May-June ACP Journal Club.
Other recent studies have shown that aspirin, while effective in non-diabetics, does not improve cardiovascular outcomes in patients with type 2 diabetes, the Journal Club reviewer noted. The reason is related to how aspirin decreases the production of thromboxane A2 (a platelet activator) and prostacyclin, which decreases platelet aggregation. An imbalance occurs in diabetics because they have numerous other platelet activators, which cancel out prostacyclin's anti-aggregating influence.
While more investigation is needed on the preventive capabilities of picotamide, the drug would be a welcome alternative to aspirin because it causes less bleeding and less frequent gastrointestinal discomfort, said the reviewer. For the present, clinicians should continue to follow the American Diabetes Association's recommendations of 75-162 mg of aspirin daily for diabetics over age 40 with vascular disease or additional risk factors.
ACP Journal Club is online.
A new federal appeals court ruling has opened the way for generic competition for Purdue Pharma's painkilling drug OxyContin (oxycodone HCl controlled-release).
Last week's ruling by the U.S. Court of Appeals for the Federal Circuit in Washington stated that Purdue Pharma misled the government to win patent protection for the drug, according to the June 8 New York Times. A June 7 text of the ruling says that Purdue led the FDA to believe that it had clinical evidence of OxyContin's four-fold dosage range (compared with eight for other opioids) and a more efficient titration process. However, the appeals court found that Purdue could not prove the accuracy of the statements scientifically.
The ruling makes patents on the drug unenforceable, said the New York Times. It also paves the way for Endo Pharmaceutical Holdings, which brought the original lawsuit, to market its generic form of the drug.
The New York Times is online.
The U.S. Court of Appeals for the Federal Circuit ruling is online.
Cardiologists are less likely to perform angioplasties in states that require public reporting of mortality rates, according to a recent study.
The study compared outcomes of 11,374 patients included in an eight-hospital percutaneous coronary intervention (PCI) database in Michigan—which has no public reporting—with 69,048 patients at 34 hospitals in New York—where reporting is required. The study is published in the June 7 Journal of the American College of Cardiology (ACC).
The raw data showed the death rate in Michigan to be twice that of the rate in New York, which researchers attributed to patients in Michigan being sicker on average than patients in New York, according to a June 7 ACC news release. When they adjusted for differences in patients, researchers found no difference in hospital death rates between the two states, suggesting that physicians in New York were less likely to treat the sickest patients.
The results indicate that physicians in public reporting states may shy away from high-risk patients because a bad outcome could bring down their grades, said the June 7 New York Newsday. The intent of New York's public access law, said the article, is to allow patients to select hospitals with the best survival rates.
An accompanying editorial noted that New York's public reporting system, while well intended, has resulted in the public getting incomplete and misleading data, the ACC release said. Overall quality improvements in New York are similar to states without public reporting, he added, suggesting that the improvements are due to other, unknown factors.
The ACC news release is online.
New York Newsday is online.
Managed care rates may go up by double-digits again next year, says a new report, but the rate of increase is slowing to its lowest point in five years.
As companies begin negotiations on next year's rates, HMOs are asking for an increase of 12.4%, according to preliminary estimates by Hewitt Associates. This Lincolnshire, Ill.-based human resources services firm tracks HMO rate information for about 160 large companies representing more than 1 million employees.
That figure is expected to lower slightly following negotiations with companies, said a June 9 Hewitt Associates news release. HMOs were asking for a 13.7% hike at the same time last year, which fell to 9% following negotiations with employers. The preliminary report projected that 2006 rates will fall to 8% to 9%—a five-year low—following the negotiation period.
While rate hikes are slowing nationally, certain geographic regions—especially the Northeast—are experiencing higher increases, said the release. To negotiate rates down this year, employers are expected to transfer more costs to employees, by, for example, increasing copays for prescription drugs, specialty care and emergency room visits. Employers have been using this tactic for the past few years. In 2001, 52% of the companies had a $5 copay; in 2005, 24% of the firms had a $5 copay.
The Hewitt Associates news release is online.
Concerned that the growing federal deficit will force cuts to the Medicaid budget, the College has published a position paper on how this ever-growing entitlement for the poor and disabled should be transformed.
The paper cites federal projections, estimating that the deficit will reach $2.3 trillion by 2013. It notes that Medicaid spending has increased by 63% in the last five years, and reports that cuts adopted in 34 states this year could cause up to 1.6 million, low-income people to lose their coverage.
Listing 14 points—from gradually eliminating the use of categorical eligibility to increasing available federal dollars during times of economic distress—the paper stresses the College's belief in the program's value as a safety-net for the poor and disabled.
Among the College's points:
Medicaid should be expanded. The College's HealthCARE Act—a plan for universal coverage within seven years—includes reforms to extend Medicaid and SCHIP, the states' provision for low-income children, which would not inflict additional, unfunded mandates on the states.
By eliminating the categorical eligibility requirement, coverage could eventually be extended to childless couples and single adults. This could be achieved by giving the states more flexibility to expand benefits.
Instead of limiting a beneficiary's access to prescription drugs to contain costs, Medicaid officials should rein in proven overpayments. States also should not restrict prescriptions.
Eligibility standards should be made uniform on a national basis.
Regarding longterm care, beneficiaries should have more options than a nursing home. Community and home health services, the paper notes, are more individualized and can be more cost effective.
As it has with unemployment insurance, Congress should establish a mechanism that would permit more federal dollars to flow into the Medicaid budget during distressed economic cycles.
The paper is online.
A new bill providing $100 million to help community-based groups locate pregnant women and children who are not enrolled, but eligible, for Medicaid and State Children's Health Insurance Program insurance, has received the College's support.
Introduced by Senate Majority Leader Bill Frist, the Covering Kids Act of 2005 would require that the Department of Health and Human Services give grants to groups who work in areas where there are high numbers of eligible but unenrolled youngsters, including those in rural areas. An estimated 5 million children fall into this category.
College President C. Anderson Hedberg, FACP, also told Dr. Frist in a letter that the College supports his proposal to allow states to use a federal minimum standard establishing eligibility that would extend benefits to the uninsured. The federal government would cover the additional costs.
The letter also stressed the College's dedication to strengthening the safety net of entitlement programs, and its belief that states should be given greater flexibility to streamline Medicaid and SCHIP enrollment processes.
The letter is online.
The bill is online.
Proposed legislation, which would help physicians and other health care providers acquire electronic health records and other technologies, has received the College's backing. The bill, the Health Information Technology Act of 2005, also calls for the adoption of uniform health information technology standards within two years.
In a letter to the bill's sponsors, Sens. Debbie A. Stabenow (D-Mich.) and Olympia J. Snowe, (R-Maine), College President C. Anderson Hedberg, FACP, told the legislators that the measure "takes a significant step toward the future expansion" of universally accepted HIT standards.
The letter also noted other significant provisions of the bill, including the authorization of adjustments to the Medicare payment system, which would recognize physicians who use HIT to manage patients with chronic illnesses; the creation of a one-time funding pool allowing grants and tax deductions for those who purchase and use EHR systems and other information technologies; and the prioritization of funding for those providers whose patient population includes many Medicare, Medicaid and State Children Health Insurance Program recipients, or who work in areas where there is a significant shortage of health care professionals.
The letter 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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