In the News for the Week of 6-28-05
- College, others, offer help crafting federal quality legislation
- Free Webinar now available on using handheld computers
Clinical news in the headlines
- Study finds antibiotics provide little relief for bronchitis
- Lung cancer study: Chemotherapy prolonged life after surgery
- FDA approves first ethnic drug for blacks
- AMA weighs in on filling RXs for contraceptives, more
- ABIM cautions physicians about geriatrics certifying group
- New online editorial discusses health information technology
Access to coverage
- Medical costs surpass wage growth for eighth straight year
ACP has joined with three other national medical societies to offer Congressional leaders help in writing federal legislation that would improve health care quality in federal health programs, including Medicare and Medicaid. Legislation could be introduced as early as this week.
The June 21 letter was signed by ACP, as well as by the American Academy of Family Physicians, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, which together represent 300,000 physicians and medical students. The letter outlined several provisions of quality legislation that the groups would support. Those included:
Giving physicians positive Medicare payment updates and reversing cuts now slated under the sustainable growth rate formula. This would make more dollars available for quality improvement programs.
Allowing physicians to receive extra payments if they participate in performance measurement and reporting programs. These programs would be phased in over several years.
Increasing physician pay based on the number of dimensions of care being measured and instituting a graduated payment structure, with incentives for physicians to participate in performance improvement programs.
Validating clinical performance measures through a multi-stakeholder process. The National Quality Forum and the Ambulatory Care Quality Alliance should be referenced in selecting measures, the letter said.
Making sure physicians aren't penalized for volume increases that occur due to performance measurement compliance.
The letter is online.
A lecture given at Annual Session 2005 on the practical applications of handheld computers is now available free to ACP members as a Web-based lecture.
The 90-minute Webinar by Peter J. Embi, ACP Member, provides an overview of handheld computers (also known as PDAs) and their use in medical practice. Dr. Embi reviews popular clinical software—including drug references, coding and billing—and patient documentation, and provides actual examples of various programs. He also discusses the limitations of handheld computers and covers useful tips and trouble-shooting techniques.
Dr. Embi, who is assistant professor of medicine at the University of Cincinnati in Cincinnati, is a rheumatologist with additional training in medical informatics. At the University of Cincinnati, he divides his practice between rheumatology and medical informatics.
The Web-based presentation is available on the ACP Online PDA Portal.
Clinical news in the headlines
A study published last week found that treating lower respiratory tract infections with antibiotics was no more effective than providing no treatment. The findings suggest that physicians can reduce their use of antibiotics to treat such infections.
In the five-year study, 640 adults and children with acute uncomplicated lower respiratory tract infections were divided into three treatment groups: immediate antibiotics, a delayed prescription or no offer of antibiotics. All three groups displayed roughly the same cough duration and resolution of other symptoms. The study appeared in the June 22 Journal of the American Medical Association (JAMA).
According to the June 22 Washington Post, coughing lasted for an average of 11 days in all three groups. Symptoms such as phlegm and shortness of breath were reduced with the use of amoxicillin or erythromycin compared with those given no prescription, but only by less than a day. In addition, those who did not receive antibiotics were slightly more likely to return within a month complaining of cough.
The findings suggest one way physicians can combat the overuse of antibiotics, a factor in the emergence of drug-resistant strains of bacteria. Otherwise healthy patients should be able to forgo antibiotics, an expert interviewed in the Washington Post said, noting that patients at high risk for pneumonia should always consult their physician.
The authors noted that not offering antibiotics or using delayed prescriptions were very acceptable to most patients. The challenge for physicians, they said, is to be more selective about prescribing antibiotics by identifying those patients most at risk for adverse outcomes.
The JAMA abstract is online.
The Washington Post is online.
Study findings published last week found that giving patients with early stage lung cancer chemotherapy after surgery significantly prolonged survival.
The study included 482 men and women with early stage non-small-cell lung cancer, who received either vinorelbine plus cisplatin following surgery or observation only. Patients in the chemotherapy group survived 94 months following surgery vs. 73 months for the observation group, with the chemotherapy patients having an absolute survival advantage of 15% over the observation group after five years. The study appeared in the June 23 New England Journal of Medicine (NEJM).
The study, along with similar results presented at conferences over the past year, has led to changes in the way physicians treat lung cancers, the June 23 New York Times reported. A few years ago, surgery alone was the standard of care for the 50,000 people a year diagnosed with early stage lung cancer in the United States, the article said. Many of those patients are now being given chemotherapy, as is common for patients with some other cancers such as breast or colon cancer.
Lung cancer is the most common cancer and the leading cause of cancer death, the New York Times said, and between 80% and 85% of cases are the non-small-cell variety. The recent study applies to early stage tumors classified as Stage IB or Stage II, which account for between 25% and 30% of newly diagnosed cases.
The survival rate of patients who undergo surgery alone ranges from 23% to 67%, according to the New York Times. Until the mid-1990s, surgery patients were advised not to have chemotherapy because the treatment often made a patient's condition worse, the article said. That's changing as newer drugs and better treatments for side effects have become available.
The NEJM abstract is online.
The New York Times is online.
The FDA last week approved a new heart drug for African Americans, the first "ethnic" drug to be marketed in the United States.
In a June 23 press release, the FDA said that approval of BiDil, which is manufactured by the Lexington, Mass.-based Nitromed Inc., marks a move toward "personalized medicine." The agency's approval was based on results from the African American-Heart Failure Trial (A-HeFT), which included more than 1,000 African American heart failure patients. The trial was halted early when BiDil—a combination of isosorbide dinitrate and hydralazine—was shown to reduce mortality by 43% compared with placebo.
Nitromed contends that marketing BiDil as an ethnic drug is justified because blacks are especially susceptible to heart failure and have not always responded to existing treatments. However, critics have expressed concern that approving a drug for one ethnic group implies biological differences between races, something for which there is no scientific evidence.
Critics also were concerned that approving BiDil for African Americans will keep it from patients of other races who could benefit, said the June 24 Washington Post. A cardiologist interviewed in the article advised physicians to prescribe the drug to any patient who fit the profile of the patients in the study, regardless of race.
The FDA news release is online.
The Washington Post is online.
The AMA last week endorsed efforts by several states to require pharmacists to fill physicians' prescriptions for medications including birth control. The group also updated guidelines on pay-for-performance programs and agreed to study the impact of direct-to-consumer drug advertising.
At its annual meeting in Chicago, the AMA's House of Delegates passed a resolution urging pharmacists who have religious or ethical objections to dispensing contraceptives or other legal drugs to provide referrals to alternative pharmacies and to return the original prescription to the patient, the June 21 Chicago Tribune reported. The AMA policy is similar to that of Walgreen Co., the country's largest drugstore chain, the article said, which allows pharmacists to object to filling a prescription on moral grounds as long as they find someone else to fill the prescription before the patient leaves the store.
Similar legislation is pending in about a dozen states, according to the Chicago Tribune. The Illinois governor took the unusual step of issuing an emergency order for pharmacies in the state to dispense contraceptives without delay.
Earlier this year, the Executive Committee of the ACP Board of Regents approved a resolution that was presented at the House of Delegates meeting last week. The resolution urged the AMA to work to see that state laws ensure that systems are in place to protect patients' access to legal therapies. The College's "Ethics Manual, Fifth Edition" states that physicians who object to providing information about reproductive issues have "a duty" to give patients information about different care options or to refer patients for such information.
The Chicago Tribune is online.
The College's ethics manual is online.
AMA delegates last week also updated guidelines on pay for performance, according to a June 22 AMA news release. The new guidelines call for pilot testing of performance measures prior to implementation and for making sure that programs do not impose penalties on physicians for factors outside of their control.
Poorly designed pay-for-performance programs are beneficial only to insurers, the news release said, and can harm patients rather than improve care.
The updated principles are available on the AMA's Web site.
The AMA news release is online.
College policy on pay for performance is online.
In other business, delegates agreed to study the impact of drug company advertising on prescribing patterns, according the June 22 New York Times. The delegates rejected a number of proposals to limit or ban drug advertising. The move comes amid debate over whether consumer advertising encouraged widespread use of COX-2 inhibitors, which have been found to carry a risk of cardiovascular problems.
The New York Times is online.
The ABIM has issued a warning, alerting physicians about an organization that claims to offer board certification for geriatrics medicine.
The group, which calls itself the American Board of Geriatric Medicine or the American Board of Geriatrics, has been writing physicians with offers of certification in geriatric medicine for a fee, according to a recent notice posted on the ABIM's Web site. The group claims that paying the fee will allow physicians to become members of the American College of Geriatrics.
The ABIM stressed that these groups are not related to the ABIM or to any recognized medical society. In its posted notice, the ABIM said the groups' purported credentials have no validity and may mislead patients about a physician's qualifications.
The ABIM notice is online.
John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, recently released the second of two Web-based video editorials on quality improvement.
In "Health Information Technology: Improving Quality and Value of Patient Care," Dr. Tooker discusses both the advantages of health information technology as well as the challenges to widespread adoption.
According to Dr. Tooker, only 17% of U.S. physicians use electronic health records on a regular basis. He notes that time, cost and practice disruption are barriers for most physicians. To encourage information technology investment, Dr. Tooker calls for the establishment of incentives, possibly through a government-backed loan program. He also states that payment policies must encourage the use of information technology so those investments can be paid off.
"The quality, safety and financial benefits that will result from the broader adoption of health information technology make this investment imperative for the future health of Americans," says Dr. Tooker.
The Medscape Webcast and editorial are available online. (Medscape registration may be required.)
Access to coverage
A recent study found that health care spending grew nearly four times as fast as wages in 2004, threatening to push more low- and middle-class Americans out of the insurance market.
Medical spending by privately insured Americans rose by 8.2% in 2004, about the same increase as in 2003, according to a report by the nonprofit Center for Studying Health System Change (HSC) that was published in the June 21 Health Affairs. But while costs have stabilized, the average hourly wage across industries rose by only 2.1% last year, the eighth year in a row that medical costs have grown faster than wages.
If the cost trend continues, more people will become uninsured and even middle-class workers will be priced out of the private insurance market, said an HSC official interviewed in the June 21 Washington Post. Outpatient services, such as X-ray imaging and angioplasty—which accounted for 54% of last year's increase—have been a large factor in driving up costs.
Rising health care costs have pushed many businesses to reduce or drop health benefits for employees, said the article. A separate survey cited by the Washington Post found that 83% of employers increased employee contributions for health coverage last year.
The Health Affairs article is online.
The Washington Post 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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