In the News for the Week of 7-5-05
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
- Gap persists between best and actual care
- Direct purchase for Part B drugs to start in 2006
- Women more likely to die from heart disease at poorly performing hospitals
- ACP Foundation offers free patient HEALTH TiPS cards
Clinical news in the headlines
The following articles appear in the July 5 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Task Force: Physicians should screen pregnant women for HIV. Updating its 1996 guidelines, the United States Preventive Services Task Force (USPSTF) now recommends HIV screening for all pregnant women. The USPSTF continues to recommend screening for all adolescents and adults at risk for HIV.
Previous recommendations called for routine screening and counseling for high-risk pregnant women and for those living in communities with high rates of infected newborns. Along with the new recommendations, this issue of Annals contains two background papers on which the recommendations were based.
New study finds that soybean protein may lower blood pressure. A new 12-week study of 302 adults with high-normal or mildly elevated blood pressure found that those eating special cookies containing 40 grams of soybean protein had significantly larger decreases in blood pressure levels than those eating similar cookies made of complex wheat carbohydrate. By the end of the study, the soybean group had a net reduction of 4.3 mm Hg systolic and 2.1 mm Hg diastolic blood pressure. Neither group reported significant side effects.
However, an editorial states that more evidence of benefit and safety are needed before physicians can recommend soybean protein to those at risk for hypertension. Forty grams of soybean protein equal about one soy burger plus one to two cups of soy milk. The editorial notes that many people may not be able to consume that much soy protein every day and that no one knows if that amount is safe. Authors of both the study and the editorial cite some evidence of an association between soy protein and increased bladder cancer risk.
The article is online.
The editorial is online.
Study: Acupuncture no better for fibromyalgia than sham acupuncture. A 12-week study of 100 people with fibromyalgia compared true acupuncture therapy with three forms of sham or fake acupuncture. Researchers found that patients receiving true acupuncture had no better pain relief than those who received the sham treatments.
The sham acupuncture therapies included needles inserted at points for treating another condition, needles inserted at points that are not acupuncture points, and use of special needle-like devices that did not pierce the skin. Participants were allowed to continue other treatments they had been using for fibromyalgia or other physical ailments.
The article is online.
A new study on the quality of U.S. outpatient care found that while more attention is being paid to evidence-based guidelines, many patients still are not receiving optimal care for many common conditions.
Using data from the CDC's National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, researchers tracked results for 23 outpatient quality indicators in 1997 and again in 2002. Significant improvements in quality were noted on only six of those indicators. The study appeared in the June 27 Archives of Internal Medicine.
The six areas where care improved over the five-year period included treatment of depression (47% vs. 83%), statin use for hyperlipidemia (10% vs. 37%), inhaled corticosteroid use for asthma (in adults, 25% vs. 42%), avoiding routine urinalysis during general exams (63% vs. 73%), and avoiding inappropriate medications in the elderly (92% vs. 95%).
In 2002, however, the percentage of visits where patients received appropriate care was less than 50% for six of the 10 chronic disease management indicators. The authors noted that while statin use increased in 2002, the drugs still were prescribed at only 37% of visits made by patients with hyperlipidemia. Similarly, proven therapies for heart disease—including ACE inhibitors, aspirin and beta-blockers—were prescribed in fewer than half of the visits where they would have been appropriate.
The authors found little difference in the care provided to minorities vs. whites, although they noted that the study did not account for disparities in access and use. In addition, they found tendencies toward lower use of aspirin and statins and less exercise counseling for non-Hispanic blacks and Hispanics with higher risk of heart disease, despite these groups being disproportionately affected by the disease.
The increased focus on evidence-based guidelines is not having much of an impact on actual care provided, the authors said, a problem rooted in the health care system’s failure to provide timely, evidence-based care. They suggested that fundamental changes are needed to close the performance gap, including physician incentives for meeting quality standards and innovative use of information technology as well as alternative delivery methods, such as outreach programs and group visits.
An Archives of Internal Medicine abstract is online.
Physicians who administer drugs in their offices will have the option of buying drugs directly from vendors under a new Medicare program beginning Jan. 1, 2006.
The competitive acquisition program will allow physicians to buy Part B drugs from vendors approved by Medicare, according to a June 27 CMS news release. The agency said that 181 of the 440 drugs covered by Part B will be included in the new program, accounting for 85% of all Medicare spending on physician-injectable drugs.
Under the new rules, participating vendors would bill Medicare and collect any coinsurance or deductibles, according to the CMS release. Physicians who choose not to participate in the direct-acquisition program would continue to purchase drugs directly from suppliers and bill Medicare at a rate of 106% of the manufacturers’ average sales price.
Physicians will be given the option to participate annually in the program and choose a vendor as their primary source for Part B drugs, the CMS said. Physicians will be paid the same for administering the drugs regardless of whether or not they participate in the new acquisition program.
According to the CMS release, the new program is designed to cut down on physician paperwork and administration. Those who participate will no longer have to bill Medicare or collect copays.
The CMS said it expects to receive vendor bids later this summer and to award contracts in the fall. The interim rule will be published in the July 6 Federal Register and comments will be accepted until Sept. 6.
The College’s comments to CMS on the competitive acquisition program are online.
The nation’s hospitals are providing better care for women with heart disease and stroke, according to a recent study, but their risk of mortality varies dramatically between the highest- and lowest-performing hospitals.
Overall, survival rates improved by 11% between 2001 and 2003 for women with heart disease and stroke, according to HealthGrades’ Women’s Health Outcomes in U.S. Hospitals study, which was released last week. However, the best-performing hospitals had a 39% lower risk-adjusted mortality rate than the poorest performers. HealthGrades is a for-profit healthcare rating organization.
Across the board, mortality rates associated with coronary artery bypass graft surgery (CABG) improved by 16%—the largest single area of improvement—while mortality from stroke showed the smallest improvement at just over 3%, according to a June 27 HealthGrades news release. However, women undergoing CABG were much less likely to die at the highest-performing hospitals, which had a 46% lower risk of mortality, than the worst-performing group.
Overall, women's mortality rate from heart disease and stroke at the top 15% of hospitals improved by 13% between 2001 and 2003 compared with less than 6% for the worst-performing hospitals, the release said. The most glaring difference in quality of care was for heart failure, with the best-performing hospitals posting an almost 24% average improvement compared with just over 4% at the worst-performing hospitals.
In addition, the release said, women treated at the top hospitals were more than 40% less likely than women treated at the worst-performing hospitals to die following percutaneous coronary interventions (PCI), heart failure or CABG surgery.
The HealthGrades study, now in its third year, analyzes women’s outcomes from more than 1,500 hospitals in 17 states for CABG, valve-replacement surgery, PCI, acute myocardial infarction, heart failure and stroke. Based on the results, HealthGrades has updated the hospitals’ ratings on its consumer Web site.
The HealthGrades news release is online.
Physicians now have access to free patient education cards that provide important information on managing chronic disease. Developed by the ACP Foundation, "HEALTH TiPS" cards covering pain and hypertension are now available.
The cards come in convenient 4x6-inch tear-away pads. Easy to read and understand, the "HEALTH TiPS" card material was created by health literacy experts specifically for patients with low health literacy levels. The cards come in English and Spanish versions.
The cards contain basic and essential patient instructions for condition management, with physician and pharmacist discussion topics clearly presented with supporting graphics. HEALTH TiPS' content is developed in conjunction with the editor and staff of ACP's PIER and reviewed by the ACP Foundation's Health Literacy Advisory Board for appropriate language and design.
The first two HEALTH TiPS cards, which focus on pain and hypertension, are now available. ACP members can order cards free of charge at the ACP Foundation Web site.
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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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