In the News for the Week of 6-7-05
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
- Defensive medicine more common in 'crisis' states, studies say
- Experimental vaccine cuts number of shingles cases in half
- After rofecoxib's removal, prices rise for brand-name alternatives
- College EVP addresses performance measures in online editorial
- College helps fund HIT certification effort
- Computerized order entry doesn't prevent adverse drug events
Clinical news in the headlines
The following articles appear in the June 7 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
- Using generic drugs could save $8.8 billion a year. U.S. adults could save up to $8.8 billion a year by using generic drugs rather than brand name ones, according to an analysis of data from a 2000 national medical expenditure survey.
By using drugs that had both a brand name and at least one identical generic formulation, researchers estimated that people younger than age 65 would each save an average of $45.89 per year, while those older than 65 would save $78.05. While the authors noted that the "absolute per person savings would be small," the overall savings would equal about 11% of all annual drug expenditures for American adults and could reduce costs without hindering quality of care.
Gulf War troops have more health issues than non-combatants. Researchers studying a sample group of veterans of the 1991 Gulf War have found that they have four more health issues than a comparable group that either had not been deployed or had served elsewhere.
Looking for evidence of 12 different medical conditions, researchers found only four that were more common among those deployed in the Gulf War: fibromyalgia, chronic fatigue syndrome, skin rashes, and indigestion or heartburn. Conditions such as high blood pressure, diabetes, hepatitis and obstructive lung disease were not more common among veterans who served in the Gulf War.
An editorial reported that the four conditions do not constitute a unique syndrome and noted that similar symptoms have been reported "after every armed conflict since the Civil War."
Hepatitis C outbreak in cancer clinic attributed to poor infection control. A new study found that the reuse of disposable syringes in an outpatient cancer clinic between March 2000 and July 2001 led to 99 people being infected with hepatitis C.
Standard infection-control protocols recommend using new sterile disposable needles and syringes for every injection. While hospitals are obligated to implement infection-control programs, outpatient, ambulatory and freestanding facilities are generally not subject to similar requirements.
Study authors say that infection-control programs must be developed and implemented for outpatient settings. These should include standards for rigorous training and oversight of health care workers, and clear procedures and responsibilities for reporting and investigating outbreaks.
An editorial called the practice of sharing saline bags and reusing syringes "egregious," and said the failure of the hospital—where the for-profit clinic was located—to report early suspected cases to the state health department or CDC was "unconscionable." According to the editorial, the study is a "sobering reminder of the shortcomings in our existing policies, our safety-net systems, and our sense of personal responsibility to provide safe care."
Two new studies on medical malpractice have concluded that fear of litigation and high malpractice premiums are leading physicians to practice defensive medicine and to avoid working in malpractice "crisis" states.
In one study, almost 93% of 824 physicians surveyed in six high-risk specialties said they often ordered extra tests, referred more patients to specialists and avoided complicated cases due to fears of being sued, according to the June 1 Philadelphia Inquirer. The study, which appeared in the June 1 Journal of the American Medical Association (JAMA), focused on Pennsylvania because physicians there have been particularly hard hit by rising malpractice premiums.
One-third of the respondents—representing emergency medicine, general surgery, orthopedic surgery, neurosurgery and ob/gyn—said they often suggested unwarranted invasive procedures, according to the study. In addition, 39% said they avoided high-risk patients, with orthopedic surgeons being the most likely to do so.
Malpractice crisis states are also more likely to have trouble attracting physicians, according to a second study in the same JAMA issue. The study, which compared supply trends in states that adopted tort reform between 1985 and 2001 vs. those that did not, found that the number of physicians in reform states increased 2.4% more than in states without reforms.
The JAMA studies are likely to bolster the case for imposing caps on noneconomic damages, the Philadelphia Inquirer said.
However, findings of a May 31 Health Affairs Web exclusive are likely to be used by opponents of those caps. Using data from the National Practitioner Data Bank, authors of the Health Affairs article concluded that the growth in malpractice payments, which is about 4% a year, is consistent with increases in the overall cost of health care.
Health Affairs is online.
The Philadelphia Inquirer is online.
In a large-scale study of older adults published last week, an experimental vaccine proved effective in preventing and easing the pain and severity of herpes zoster (shingles).
The study included more than 38,000 healthy adults age 60 and over. Participants were vaccinated with a more potent version of the varicella-zoster vaccine and followed for three years. Results showed a 61% reduction in pain and discomfort associated with zoster, a 67% reduction in the incidence of postherpetic neuralgia and a 51% reduction in the incidence of herpes zoster. The study appeared in the June 2 New England Journal of Medicine (NEJM).
The results could be significant because zoster affects hundreds of thousands of people each year, most of them over age 50, according to an accompanying NEJM editorial. In many patients, pain persists for more than a year and is not easily controlled by topical or oral medications. The condition occurs more frequently among patients with poor immunity, including AIDS and chemotherapy patients and organ transplant recipients.
The experimental vaccine also appears to be safe, the editorial pointed out. In the study, 1.4% of recipients suffered serious adverse effects or death among both the vaccine and placebo groups. According to the editorial, two factors will influence the future administration of the vaccine: whether adults who have been vaccinated as children (which includes most younger adults) will have similar response rates as adults in the study, most of whom actually contracted chickenpox; and whether the vaccine is cost-effective.
Merck, which developed the vaccine, has already applied for FDA approval and hopes to receive it by February 2006, the June 2 New York Times reported. The article said that widespread use of the vaccine in people over age 60 could prevent 250,000 zoster cases a year.
The NEJM abstract is online.
The New York Times is online.
The price of other nonsteroidal anti-inflammatory drugs (NSAIDs) has risen between 2% and 9% in the six months following the September 2004 withdrawal of rofecoxib (Vioxx), according to a report released last week.
Prescriptions for meloxicam (Mobic) increased by 136% during those six months, the sharpest increase of any of the NSAID alternatives, according to a June 2005 analysis by Consumer Reports Best Buy Drugs, a free public information and education project. According to the report, the price for meloxicam rose by 9%, three times the average 2.4% increase for all NSAIDs.
The average national monthly cost for meloxicam in March was $111 for the 7.5 mg dose and $157 for the 15 mg dose, said an accompanying Consumer Reports June 2 news release. Authors of the report noted that ibuprofen, naproxen and salsalate are $50 per month or less and are as effective as other drugs in the class.
John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, recently released a Web-based video editorial on the country's need to measure quality and assess physician performance.
In his "The Importance of Measuring Quality and Performance in Health Care" editorial, Dr. Tooker commented on both the potential for performance measures to improve the quality and efficiency of patient care and on the challenges of developing a coordinated strategy to collect and combine performance data. The hundreds of different measurement sets being initiated by health plans and purchasers represent a burden for physicians, Dr. Tooker said, as well as confusion for patients.
That's why the recent announcement of the Ambulatory Care Quality Alliance (AQA)—a national consortium of key health care stakeholders, including ACP—is so important, he said. The AQA reached consensus on a uniform starter set of 26 ambulatory care performance measures, which could be incorporated in pay-for-performance programs around the country as early as next year.
"The adoption of appropriate quality-improvement strategies will, if done right, result in increased patient and physician satisfaction," Dr. Tooker said. "We want to ensure that it is done right."
The Medscape Webcast and editorial text are available online.
For more information on the AQA, see "Market forces push pay for performance" in the May ACP Observer.
The College has joined a coalition of health care organizations to grant over $100,000 in unrestricted funding to support the development of a standard process for certifying health information technology (HIT) products by the end of this year.
Funds totaling more than $100,000 will support the ongoing work of the Certification Commission for Healthcare Information Technology (CCHIT), according to a June 6 CCHIT news release. The CCHIT, which was formed in 2004 by the American Health Information Management Association, Healthcare Information and Management Systems Society, and the National Alliance for HIT, is an independent private-sector initiative to certify HIT products.
The work of the CCHIT will help internists and other health professionals in their decision-making by providing objective evidence that competing electronic medical record (EMR) products meet standards of functionality and operability. Products that meet functionality standards will support the clinical functions physicians need, while operability standards will allow EMRs to communicate with other EMR systems.
The new funding will allow CCHIT to deliver a certification program by the end of 2005, said College Executive Vice President and CEO John Tooker, FACP. The Commission completed the first round of public comment on its work on May 18 and plans to publish its phase two results on July 11, followed by a 30-day period for public comment.
Information about public meetings to be held from July 12-21 can be found on the group's Web site, the news release said. The group plans to pilot test a final version of its products with actual electronic health records in the fall.
CCHIT was launched in response to the national focus on increasing the use of HIT, said the news release. Besides the College, other groups that contributed to the recent funding included the American Academy of Family Physicians, the Hospital Corporation of America, McKesson Information Solutions, Sutter Health, United Health Foundation and WellPoint Health Networks.
A CCHIT news release is online.
A recent study determined that one large computerized physician order entry (CPOE) system often reduced errors, but failed to prevent many adverse drug events.
The study, which included 937 randomly selected admissions during a 20-week period at a Veterans Affairs hospital, analyzed adverse events that called for a changed treatment plan.
Researchers identified 483 adverse events, or 52 for every 100 admissions. Out of the total number of adverse events, 9% resulted in serious harm. Findings appeared in the May 23 Archives of Internal Medicine.
Most of the events were not caused by medication errors, according to the May 31 New York Times. Instead, the CPOE system lacked adequate decision-support to allow physicians to take into account multiple factors related to drug selection, dosing and monitoring. ACP's Physicians' Information and Education Resource (PIER) provides decision support that can be used in electronic medical records and CPOE systems.
The authors noted that potential purchasers of CPOE systems should look carefully at decision support functions. When a doctor enters an order for a loop diuretic, for example, the decision-support function of the CPOE system should suggest an order for a potassium supplement, as well as orders for monitoring serum creatinine and potassium levels. The authors also noted that 93% of adverse events in the study were dose-related, suggesting that some systems fail to incorporate individual unsafe dosage ranges when checking orders.
The Archives of Internal Medicine abstract is online.
The New York Times is online.
Information about PIER 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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