In the News for the Week of 7-26-05
Pay for performance
- College President gives Congress pay-for-performance recommendations
Clinical news in the headlines
- FDA issues warning on abortion pill
- Tracking care boosted clinical scores at hospitals
- Free tools now available for diabetes management
- National statistics posted on cancer incidence, detection, prevention
- College members take part in national smoking interventions survey
- ACP releases video of "Internal Medicine Report" highlights
Pay for performance
College President C. Anderson Hedberg, FACP, testified before a House subcommittee last week, saying that ACP supports creating a framework for performance improvement and reporting in the Medicare program, including creating financial incentives to reward better performance.
Dr. Hedberg warned, however, that such a program must be carefully designed to minimize the risk of unintended adverse consequences. In addition, he stressed that pay for performance is not a substitute for a broader re-examination of dysfunctional Medicare payment policies that discourage effective management of patients with chronic illnesses.
In outlining the College's position before the House Ways and Means' Subcommittee on Health, Dr. Hedberg made several recommendations about pay-for-performance programs that will be included in proposed "value-based purchasing” legislation. (Value based purchasing means giving Medicare the authority to consider the value—in quality and cost—of services provided by physicians and other providers in designing reimbursement policies.)
Any such program in Medicare needs to be phased in gradually, Dr. Hedberg said, beginning with basic measures that allow physicians to self-report that they have acquired the capabilities to do quality reporting. Later, physicians would be rewarded for participating in programs that use evidence-based clinical measures. Payment based on the measures themselves should not occur, he said, until sufficient experience was obtained in the pay-for-reporting/pay for participation stages. He also made the following recommendations:
Congress should repeal the Medicare sustainable growth rate (SGR) formula and replace it with updates that sufficiently compensate physicians for increases in the costs of providing services and to reward them for participating in performance measurement and improvement programs.
Data collection for such programs should not impose an unreasonable administrative burden on physicians.
Medical specialty societies should develop all performance measures, which should then be validated through a multi-stakeholder consensus process.
The initial framework for value-based purchasing should be followed by a comprehensive reexamination of Medicare payment policies, resulting in the creation of models designed to reward physicians who successfully coordinate care of patients with chronic diseases.
Dr. Hedberg also told the House subcommittee that value-based purchasing programs should be carefully evaluated to make sure they don't damage physician-patient relationships through additional administrative hassles and less time available to spend with patients.
The full testimony is online.
The CMS last week announced that it will help physicians computerize patient records by offering them free software, starting next month.
The electronic medical record software—a program called Vista—has been used for two decades by the Department of Veterans Affairs, according to the July 21 New York Times. While the government paid to develop the software, the article said, the program is not privately owned so it can be enhanced or modified.
According to an expert interviewed in the article, the cost of installing Vista would be $10,000 to $12,000 per practice, compared with $20,000 to $25,000 per physician for a typical commercial system. The New York Times reported that an office with five physicians stands to save more than $100,000 by using Vista over private vendor software.
The historic disadvantage of Vista is that is difficult to install, according to the article. However, Medicare plans to provide a list of companies qualified to install and maintain the system.
While the unmodified version of Vista has been available for some time, Medicare plans to alter it for physician practices, said the New York Times. In August, the CMS plans to release a new program called VistaOffice, which is reportedly easier to install than the VA version.
The New York Times is online.
The College has sent a letter to Senate leaders, asking Congress to create a sustained funding source to allow small physician practices to buy health information technologies.
The letter, dated July 20 and signed by College President C. Anderson Hedberg, FACP, said that Congress has a key role in promoting the adoption of uniform information technology standards and in providing "initial and ongoing funding mechanisms" for small practices.
According to the letter, the federal government has determined that a national health information technology infrastructure could save public and private payers as much as $170 billion per year, nearly 10% of total U.S. health spending. However, Dr. Hedberg stressed, under current payment and incentive systems, public and private payers would reap those financial benefits, not physicians.
Dr. Hedberg made the following recommendations:
The government must change current reimbursement policies so physicians can be rewarded for improving the quality of care. That would allow physicians to share in savings accrued through information technology.
Physicians who participate in pay-for-performance programs and invest in technologies should be compensated. The College recommends that Congress build into the Medicare physician payment system an add-on code for office visits and other evaluation and management services that recognize the use of information technology.
Congress should allocate funds to small practices to make the initial investment in hardware and software.
Congress must push for the adoption of uniform standards. While some standards have been developed by public and private entities, legislators should convene one decision-making body to deal with the issue of uniform standards, Dr. Hedberg advised.
Dr. Hedberg's letter is online.
Clinical news in the headlines
A study published last week found that atorvastatin did not help very ill diabetics on dialysis and it doubled their risk of suffering a fatal stroke.
In the study, 1,255 patients with type 2 diabetes mellitus and on hemodialysis received either 20 mg of atorvastatin daily or placebo. After four weeks, patients in the atorvastatin group had lowered their LDL cholesterol by 42%, but they did no better than the placebo group in their combined risk for heart attacks, stroke and death after four years.
In addition, those taking atorvastatin were twice as likely as those on placebo to experience a fatal stroke. (The rate of fatal and nonfatal stroke increased over the course of the study from 7.0% to 9.7%.) The study appears in the July 21 New England Journal of Medicine.
The authors noted that patients taking atorvastatin lowered their LDL cholesterol to 72 mg/dL, close to the 70 mg per deciliter recommended by the National Cholesterol Education Program for people at high risk of heart disease. They concluded that patients whose kidneys have failed and who have LDL cholesterol levels between 80 and 190 mg/dL might not benefit from routine statin treatment.
More than 120,000 diabetics in the United States are on dialysis, noted the July 22 Washington Post, and atorvastatin (Pfizer’s Lipitor) is the most frequently prescribed medication. This study, sponsored by Pfizer, is surprising, according to the Washington Post, because previous studies have shown that atorvastatin helped diabetics without end-stage renal disease.
The New England Journal of Medicine abstract is online.
The Washington Post is online.
Two studies provide new evidence that the entire class of COX-2 inhibitor drugs increase the risk of cardiovascular events.
In one trial, patients with a history of colorectal neoplasia were given either 200 mg or 400 mg of celecoxib twice daily, or placebo. The trial was halted after three years because patients receiving 800 mg of celecoxib daily had a significantly greater risk of heart attack and stroke than patients on lesser doses or placebo.
A second trial found that patients with colorectal adenomas who received 25 mg of rofecoxib daily were more likely to suffer thrombotic events than patients on placebo. Both studies are abstracted in the July-August ACP Journal Club.
Most experts say the increased risk is due to COX-2s selectively inhibiting endothelial prostacyclin synthesis without blocking the synthesis of thromboxane A2, resulting in platelet aggregation and vasoconstriction. The risks were not immediately apparent, said the commentator, partly because patients treated with COX-2s typically are older and sicker than patients given traditional NSAIDs, making it difficult to isolate the causes of heart events.
Given the popularity of these drugs, the commentator said, it is likely that COX-2 drugs have already contributed to many unnecessary deaths. However, only rofecoxib has been removed from the market, leaving physicians and patients to weigh the risks of using other drugs in the class.
This new evidence suggests that physicians should consider restricting the use of COX-2 inhibitors to those patients without overt vascular disease who are at risk for gastrointestinal bleeding or can't tolerate other NSAIDs, the commentator said. When prescribing the drugs, physicians should use the lowest dose for a minimum length of time.
The FDA last week asked health professionals to be on the alert for sepsis in women who have taken mifepristone to induce abortions.
The warning came after two more women taking the pill died of infections. The two cases, reported in April and June of this year, are in addition to two earlier cases of death from sepsis in women taking the pill, also known as RU-486, according to a July 19 FDA news release. All of the cases involved women who did not follow approved usage instructions on the pill's labeling.
Women take the drug, sold by Danco Laboratories as Mifeprex, along with misoprostol to terminate a pregnancy up to 49 days after the beginning of their last menstrual cycle, the July 20 Washington Post reported. The label instructs women to swallow both pills, but most abortion clinics tell patients to insert misoprostol vaginally, the Washington Post said. The four sepsis deaths occurred in women who used this method, but the FDA said that it did not know whether this off-label use caused the deaths.
Two of the reported infections involved Clostridium sordelli, a common germ, said the Washington Post. The FDA asked doctors to have a higher level of suspicion for sepsis in patients taking mifepristone, but said the pill is still safe enough to remain on the market.
An FDA official interviewed by the Washington Post noted that the rate of sepsis is about 1 in 100,000 for mifepristone, similar to the risk associated with a surgical abortion or childbirth. The advisory comes eight months after the FDA warned about the first two sepsis cases, which led to revising mifepristone’s black box labeling.
The FDA news release is online.
The Washington Post is online.
Research released last week found that hospitals participating in a two-year performance measurement program significantly improved their scores in three key clinical areas, with the hospitals that initially posted the worst results being the most likely to improve.
The study, done by researchers with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), focused on three clinical categories: acute myocardial infarction (MI), congestive heart failure and pneumonia. Between 2002 and 2004, improvement ranging between 3% and 33% was noted in 15 of the 18 measures for all three categories, based on data from more than 3,000 accredited hospitals. The study appears in the July 21 New England Journal of Medicine (NEJM).
An accompanying editorial noted that hospitals approached optimal performance on five measures involving beta-blockers for acute MI and oxygenation assessment for pneumonia. One of the measurements that showed the most improvement across all three categories was in counseling for smoking cessation.
Researchers also reported that hospitals that started off as the poorest performers improved the most over the two years. That finding is significant, they said, because it suggests that requiring hospitals to submit data and giving them regular progress reports are effective incentives to improve.
Another study in the same NEJM issue found geographical differences in quality among hospitals participating in the CMS Hospital Quality Alliance program. The study found that, overall, Midwestern and Northeastern hospitals performed better than Southern and Western hospitals in treating acute MI, congestive heart failure and pneumonia. Hospitals in cities in the North and Central regions dominated the top performers' list, while those in the Southeast and Southwest were more likely to be ranked near the bottom.
Physicians can now download free evidence-based educational materials for patients and clinicians on managing diabetes.
Created by the National Diabetes Education Program (NDEP), the free material draws on evidence-based national guidelines for diabetes diagnosis and care. The NDEP is a federally funded program sponsored by the NIH and the CDC, and includes more than 200 partners working to reduce the morbidity and mortality associated with diabetes.
The NDEP materials include:
"Diabetes Numbers at-a-Glance" reference card. This pocket guide for health care providers includes American Diabetes Association recommendations for diabetes diagnosis and management.
"Guiding Principles of Diabetes Care." This eight-page booklet provides information on providing comprehensive patient-centered care, with ways to identify, treat and prevent long-term complications.
"Small Steps. Big Rewards. GAMEPLAN for Preventing type 2 diabetes." This 32-page publication is geared toward patients and gives them information on how to start their own prevention program, including ways to treat pre-diabetes. It also has counseling and motivating tips for patients, and includes posters and handouts.
Call 1-800-438-5383 to order materials or download them for your practice.
The American Cancer Society (ACS) is making its "Cancer Prevention and Early Detection Facts & Figures 2005" report available to physicians and the public via a free download.
The 60-page report provides a detailed look at cancer in this country, discussing preventable risk factors like tobacco use, obesity and poor nutrition, with nutritional guidelines and information. The report also presents statistics and discussions on screening for breast, cervical and colorectal cancers.
In addition, the report provides information on community, legislative and environmental initiatives being used to improve modifiable cancer risk factors.
The publication is free online.
College members also can link to the ACS' "Facts & Figures 2005" report from the College's "Expert Guide to Oncology" catalog page.
A survey designed to learn how physicians deal with their patients' tobacco use is being sent to doctors nationwide, including 1,900 College members. Some 17,000 physicians in four specialties—internal medicine, family medicine, obstetrics/gynecology and psychiatry—are being asked to participate.
The survey is being conducted by the Association of American Medical Colleges in conjunction with physician organizations, including the College, and the Center for Health Workforce Studies, a nonprofit research center that surveys issues involving the health care workforce. The point of the study is to develop programs and policies that help physicians' efforts in reducing patient tobacco use.
Survey responses are due next month.
In a letter that accompanied the 28-question survey to participating ACP members, John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, said that internists have a major role in reducing patients' tobacco use because internists are in such frequent contact with patients. The information gleaned in the survey, Dr. Tooker wrote, will help the College target and advocate for the resources needed to promote smoking cessation.
Survey recipients should return responses in the stamped-return envelope included in the packet, or mail responses to: Center for Health Workforce Studies, School of Public Health, University of Albany, One University Place, Rm. B-334, Rensselaer, NY 12144-3456.
For more information on the study, contact Bonnie Primus Cohen, project director, at 518-402-0250 or firstname.lastname@example.org.
A press release is online.
Highlights from ACP's "Internal Medicine Report" monthly video news release program are now available in a Web-based video showcasing the College's success with the series.
The monthly medical and health-related broadcast reports for television news stations feature new research from Annals of Internal Medicine, clinical guidelines and public policy issues related to internal medicine. Since its launch in 2001, the "Internal Medicine Report" has been shown in every American TV market and has reached over 500 million viewers, with news and information related to internal medicine.
The highlights video is online. (To view the video, you need a version of Microsoft Windows Media Player.)
This month's Internal Medicine Report is also online on the DoctorsforAdults.com Web site.
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Copyright 2005 by the American College of Physicians.
A 62-year-old man is evaluated for declining exercise capacity over the past year. He was diagnosed with moderate COPD 3 years ago. His symptoms had previously been well controlled with tiotropium and as-needed albuterol. He has not had any hospitalizations. He is adherent to his medication regimen, and his inhaler technique is good. Following a physical exam and review of previously performed chest radiographs and pulmonary function testing, what is the most appropriate management?
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