In the News for the Week of 8-16-05
Clinical news in the headlines
- Highlights of Annals of Internal Medicine
- Clinical guidelines fall short in care for older, chronically ill patients
- Two-part therapy better than combination for osteoporosis
- Staph infections exact heavy toll at U.S. hospitals
ACP Journal Club update
- ACP Journal Club launches early publication
Business of medicine
- Physician compensation rising--but large groups still post losses
- Payments for high-tech services pushing up cost of care
- Medicare drug premiums dropping as insurers compete for market share
- Consumers rank cost over choice in health plan survey
Clinical news in the headlines
The following articles appear in the Aug. 16 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Study: Vulnerable older patients who receive quality care live longer. A study of 372 vulnerable older patients living in the community and cared for by two managed care organizations found that those who received standard-based care for numerous conditions had better survival rates than those whose care did not meet these standards.
Researchers created a quality-of-care score based on 236 process-of-care quality measures, such as annual influenza vaccination, annual evaluation of urinary incontinence, weight measurement per visit and, for those with diabetes, blood pressure check per visit, glycated hemoglobin levels measured at least every 12 months and more. Survival improved steadily as patients' quality score rose.
Although the link between standard process of care and patient outcomes is logical, the authors say that "the relationship between performance on process-of-care quality indicators and better health outcomes remains a largely untested assumption" for older patients receiving care in community or ambulatory settings.
Warfarin plus aspirin benefits some heart patients. A new study found that treatment with a blood thinner plus aspirin was beneficial for people who had a low risk for bleeding after a heart event. Researchers analyzed data from 10 randomized trials involving 5,938 patients who had a coronary event--such as a heart attack or angina--and who did not have a stent.
Patients who survive coronary events are at high risk for arterial blood clots and for repeated heart attacks, while both warfarin and aspirin can be used as blood thinners to prevent clots and stroke. In this study, patients with low to average risk for bleeding who took warfarin plus aspirin had fewer subsequent heart events than major bleeding episodes.
Researchers cite other data showing that only half of eligible patients receive warfarin therapy, while therapy with another drug--clopidogrel--is popular even though it has been shown to be less effective than warfarin in reducing heart attack and is not cost effective. Researchers urge primary care physicians to prescribe warfarin plus aspirin to eligible patients.
Clinical guidelines fall short in care for older, chronically ill patients
A study released last week concluded that doctors' clinical judgment should take precedence over practice guidelines in the care of older patients with multiple chronic conditions.
The review found that most clinical guidelines are not modified for older patients with multiple comorbidities and do not incorporate patient preferences into treatment plans. The study reported that if all of the applicable guidelines were followed for a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension and osteoarthritis, the patient would be on 12 medications and 19 doses per day costing $406 per month, possibly leading to adverse interactions between drugs and diseases.
The study, which appeared in the Aug. 10 Journal of the American Medical Association (JAMA), used data from the National Health Interview Survey and a nationally representative sample of Medicare beneficiaries, as well as the National Guideline Clearinghouse. Researchers looked at some of the most common chronic diseases seen in primary care including hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease and osteoporosis.
The findings have implications for pay-for-performance programs, noted the Aug. 10 New Jersey Star-Ledger. Quality of care is being linked to physicians' adherence to guidelines, but current guidelines are aimed primarily at managing single diseases.
Using single-disease clinical practice guidelines as a basis for deriving reimbursement for physicians who care for older patients with multiple conditions could create inappropriate incentives, the authors said. Current pay-for-performance initiatives encourage a single-disease approach, they said, and fail to reward physicians for managing complex cases.
Pay-for-performance programs need to incorporate standards for older patients who have three or more chronic diseases, which represent half of the population older than 65, they continued.
The authors recommended that future Medicare pay-for-performance initiatives take into account how to incorporate quality of life and the risks, benefits and burden of recommended treatments for this population. Training physicians to incorporate these issues into evidence-based care, they added, is another important consideration.
The JAMA abstract is online.
The New Jersey Star-Ledger is online.
Study finds two-part therapy better than combination for osteoporosis
A recent study found that following parathyroid hormone therapy with alendronate produced better outcomes for postmenopausal women with osteoporosis.
The trial included about 120 women who received parathyroid hormone (1-84) alone for one year, followed by either one year of alendronate or placebo. Researchers found that those who took alendronate had significant increases in bone mineral density compared with the placebo group, especially in the trabecular bone at the spine, while those on placebo lost substantial bone mineral density. The study appeared in the Aug. 11 New England Journal of Medicine.
Women who took alendronate in the second year of the study had a 31% increase in trabecular bone density compared with a 14% increase in the placebo group. The study found that combining parathyroid hormone with alendronate had no advantage over either treatment alone, and that alendronate tended to lessen the effect of parathyroid hormone on trabecular bone density.
The authors noted that human parathyroid hormone 1-34, or teriparatide, which stimulates bone formation, is one of two classes of drugs approved for osteoporosis. The other class--antiresorptive drugs--reduces bone resorption. While past studies have shown no advantage to combining the two drugs, this study suggests that women risk losing the positive effects of parathyroid therapy if it is not followed by antiresorptive therapy, such as alendronate.
The New England Journal of Medicine abstract is online.
Staph infections are leading to thousands of deaths every year and costing U.S. hospitals billions of dollars, according to a new study.
Results published in the Aug. 8 Archives of Internal Medicine estimated that staphylococcus aureus infections result in nearly 12,000 inpatient deaths annually, 2.7 million extra days in the hospital and $9.5 billion in excess charges. The study was a retrospective analysis of the 2000-01 editions of the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample database, which represents about 20% of U.S. hospitals.
Compared with non-infected patients, inpatients with staph infections stayed in the hospital three times longer (an average of 14 days) and had five times the risk of in-hospital death (11% vs. 2%). Almost 1% of all inpatients in the study acquired the infection during their hospital stay.
Between 40% and 60% of staph infections are resistant to antibiotics, according to the Aug. 9 Chicago Sun-Times. The elderly--as well as those with kidney or lung disease, or diabetes--are most vulnerable, the article said. Preventive measures include hand washing, prescribing the correct antibiotics and covering the skin when inserting central IV lines.
The Archives of Internal Medicine is online.
The Chicago Sun-Times is online.
ACP Journal Club update
Starting with its September/October issue, ACP Journal Club will offer permanent early publication, publishing study abstracts to the ACP Journal Club Web site as those abstracts become available. Many abstracts may be posted online as much as early as five weeks before their actual print publication date.
The move to establish permanent early publication came after an 18-month early publication trial. During three months of the trial, the ACP Journal Club Web site received 4,400 more hits than during a previous three-month period, suggesting that readers appreciated the journal's early publication format.
ACP Journal Club is a bimonthly publication featuring expert reviewers who present abstracts of leading peer-reviewed biomedical studies and reports. ACP Journal Club is free to College members.
For early publication access, see the ACP Journal Club Web site.
Business of medicine
A new physician compensation survey of large medical groups found that while most specialists' incomes went up in 2004, many groups in the Northern and Eastern regions of the country operated at a loss.
Primary care specialties saw increases of between 6% to almost 9% after several years of declining compensation or small increases, according to an Aug. 10 news release from the Alexandria, Va.-based American Medical Group Association (AMGA), which conducted the 2005 Medical Group Compensation and Financial Survey. Internal medicine compensation increased by more than 7.5%, while family medicine compensation rose by 6.4%.
Among all specialties, the largest compensation increases were in general surgery (8.9%), pediatrics and adolescent medicine (8.8%), and hematology and oncology (8.5%), the release said. By contrast, specialties that had some of the largest hikes in 2003 did not fare as well, with general cardiology, cardiac/thoracic surgery and gastroenterology recording increases in the 1% range.
Despite the compensation increases, groups in the Northern United States had an average loss of $1,365 per physician, compared with a loss of $3,477 per physician in 2003, the AMGA release said. Groups in the Eastern United States operated at a loss for the first time in four years, posting an average loss of $784 per physician compared with a profit of $2,080 per physician the previous year.
Groups in the Southern and Western regions performed better than other groups but still worse than in previous years, the release reported. Southern groups had an average profit of $40 per doctor, while the per-physician group profit in the Western region declined from $1,530 in 2003 to $479.
AMGA officials attributed the poor financial performance of many large groups in part to the current transaction-based reimbursement model, which does not reward investments in technology or other innovations that lead to improved patient outcomes. The AMGA survey includes data from about 34,500 physicians in mostly large medical groups.
The AMGA news release is online.
Prices for high-tech cardiac and orthopedic services have ignited intense competition among physicians and hospitals and are driving up the cost of health care, according to a study released last week.
Physicians and hospitals have become more entrepreneurial as a way to counteract declining or stagnant reimbursement rates, said an Aug. 9 news release from the nonprofit Center for Studying Health System Change. That trend is driving competition between the two groups as both attempt to add more profitable specialized services such as high-end imaging, cardiac and orthopedic services.
The study, based on site visits to 12 communities and interviews with officials in government, industry and insurance, appeared in the Aug. 9 online Health Affairs.
Many physicians are offering services such as MRI, radiation therapy and outpatient cancer care, the release said, which do not have physician self-referral restrictions. While competition in other sectors of the economy usually leads to lower prices, this is not always true in health care, the study pointed out, because care is paid for by third parties that reimburse providers for certain services based on billed charges rather than relative costs.
The increased focus on more profitable services could hurt access to care, said the study authors. For example, general hospitals may find it harder to subsidize charity care or expensive trauma and burn centers if their more profitable services are taken away by specialty and physician facilities. In addition, they said, physician ownership of specialty facilities often leads to more referrals, which again drives up overall cost of care.
The authors made several policy recommendations aimed at adjusting payment rates for certain services, including having Medicare partner with major medical societies to conduct a relative value survey of physician services. Medicare could also assume higher capacity use rates when setting payments for services involving expensive equipment, the authors suggested, by raising its uniform utilization rate from 50% to 75% over the life span of equipment.
Medicare announced last week that intense competition among private insurers has driven down the estimated premium for the new Medicare drug benefit by $5 per month.
The new average monthly premium will be $32.20 when the program begins in 2006, according to an Aug. 9 Medicare fact sheet. Medicare's costs are also expected to be less than expected in the first year of the program, with the per-beneficiary cost now estimated at $1,129--14% less than earlier estimates, the Aug. 10 New York Times reported.
The government said the lower costs would make the drug benefit accessible to more beneficiaries, but Medicare is anticipating having trouble getting seniors to sign up, said the New York Times. Initially, about 39 million people were expected to receive coverage starting in 2006, but that estimate was lowered last week to between 28 million and 30 million.
An insurance industry consultant quoted in the article noted that insurers likely would raise premiums in 2008, when the government drops protections against large losses on their Medicare drug business. Insurers' main strategy for the first two years of the program, the New York Times said, is to secure market share.
Details of the drug benefit will be announced in September after contracts with insurers are signed. Insurers can begin marketing to consumers in October and beneficiaries can start enrolling Nov. 15.
The Medicare fact sheet is online.
The New York Times is online.
In survey results released last week, HMOs scored higher with consumers than preferred provider organizations (PPOs), indicating that patients are more willing to give up choice to pay a lower premium.
The survey ranked 35 HMOs and 41 PPOs based on responses received between May 2003 and April 2004 from 35,000 Consumer Reports readers. Kaiser Permanente's HMOs in Oregon and Washington state scored highest on the national health plan survey, while Blue Cross's Personal Choice was selected as the top PPO. Results were reported in the September 2005 issue of Consumer Reports magazine.
While some plans ranked high with consumers, only 64% of those surveyed said they were completely or very satisfied with their plan. In addition, the survey found that 47% of respondents paid more than $1,000 in premiums during the previous 12 months, compared with 37% who had paid more than that amount in 2002.
People in HMOs had more trouble accessing care than people in PPOs, the magazine reported. However, patients in PPOs reported more billing problems-nearly three times the rate of people in HMOs.
Consumer Reports 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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