In the News for the Week of 8-23-05
Clinical news in the headlines
- New heart guidelines stress prevention, early treatment
- ACP Journal Club: Little evidence supports the efficacy of self-help weight-loss programs
Health care disparities
- Studies report slow progress in improving care for blacks
- ACP members get discounted registration for information technology summit
- Proposed rule would require nursing home immunizations
- Aetna begins posting physician prices online
- Overseas fellowship in global health, clinical research now offered
- Fellowships available in health services
- HHS solicits comments to its Healthy People 2010 revisions
Clinical news in the headlines
New heart failure guidelines released last week emphasize the importance of making early diagnoses, controlling risk factors and taking advantage of the latest treatments.
The guidelines, developed by the American Heart Association (AHA) and the American College of Cardiology (ACC), stratify heart patients according to risk, according to an Aug. 16 AHA statement. Those categories are as follows:
- Stage A and B patients lack obvious symptoms but may have, for example, a change in the structure of the heart;
- stage C patients exhibit current or past heart failure symptoms, such as shortness of breath; and
- stage D patients have refractory heart failure and may require advanced treatment, such as cardiac transplantation or end-of-life care.
Physicians were advised to recognize and treat major risk factors--including hypertension, diabetes and coronary artery disease--as soon as possible, the statement said. Getting hypertension under control, for example, can reduce the incidence of heart failure by 50%.
The guidelines drop "congestive" from the condition's name to emphasize that congestion is not always present in people at risk who may have an abnormal heart or poor cardiac output, according to the statement. The guidelines also stress that heart failure is chronic and should be treated on an ongoing basis.
Among the recommendations: using left ventricular assist devices as "destination" therapy--as opposed to a temporary measure--in some patients with end-stage heart failure; expanding the range of patients eligible for implantable cardioverter defibrillators; and paying more attention to end-of-life support issues, such as hospice care.
The aging population and an improved heart attack survival rate led to an increase in hospital admissions for heart failure from 810,000 in 1990 to more than 1 million in 1999, the statement said. In the United States, about 5 million patients have been diagnosed with heart failure and about 550,000 new diagnoses are made annually, accounting for almost $30 billion in health care costs in 2005.
The AHA statement is online.
ACP Journal Club: Little evidence supports the efficacy of self-help weight-loss programs
A review of 10 studies on the efficacy of commercial weight-loss programs found that most programs do not help people lose or keep off weight.
The review, abstracted in the July-August ACP Journal Club, looked at 10 studies on programs that provided personal or online counseling to patients for more than 12 weeks and that tracked participants for at least a year following treatment. Only one program--Weight Watchers--had modest success, with participants who attended regular meetings losing 3.2% of their initial weight after two years. However, there was no improvement in obesity-related conditions.
Weight-loss plans that do not require medication have low medical risk with tremendous potential benefits, said the Journal Club reviewer. However, it remains to be seen whether these programs are cost effective and whether repeated failures have significant adverse psychological consequences for individuals.
The complex nature of weight loss demands a more comprehensive study, the reviewer said. Ideally, such a study would be open to anyone who wanted to lose weight and participants would be stratified by their readiness to change and the extent of their weight problem, he wrote. Studies should also include screening and evaluation of food habits to steer participants into individually tailored food plans.
ACP Journal Club is online.
Health care disparities
According to three recent studies, disparities in health care between blacks and whites have narrowed over the past decade but blacks are still less likely than whites to receive basic screening and medications for common ailments.
The most positive findings among the three studies came from a study on Medicare managed care plans provided between 1997 and 2003. That study showed improvements in overall clinical performance on nine selected measures for both whites and blacks. That study also found that racial disparities had decreased on seven clinical measures. The three studies were published in the Aug. 18 New England Journal of Medicine (NEJM).
However, the same study found that racial disparities increased over the seven-year period in glucose control for diabetic patients (from 4% to 7%) and cholesterol control among patients with cardiovascular problems (from 14% to 17%). Despite the improvements on many measures, blacks in the study were still less likely than whites to be screened for breast cancer or receive basic care for diabetes and heart disease. The study was based on HEDIS reports from 183 Medicare managed care plans.
Another study found that the gap in care between whites and blacks did not improve between 1992 and 2001 for important surgical procedures, such as heart bypass, while the third study reported racial differences in the use of reperfusion therapy and coronary angiography following myocardial infarction.
The causes of persistent disparities are still being debated, according to the Aug. 18 Washington Post. Socioeconomic differences, access to quality care, cultural and biological differences, and racism are among the theories put forth.
The studies indicate that gaps in care are wider for more complex procedures, the Washington Post reported. In the managed care study, for example, disparities improved for basic care such as drug prescribing, but the surgical study found a widening gap between blacks and whites for back surgeries, carotid endarterectomies, hip replacements and appendectomies.
The studies also emphasize the importance of quality measurement and reporting to track disparities in care, according to an NEJM editorial. The editorial suggests that quality improvement activities associated with reporting can lead to overall improvements in care quality and reductions in racial disparities.
Links to the three NEJM abstracts are online.
The Washington Post is online.
ACP has long advocated for reducing racial disparities and for increasing the number of minority physicians. A College position paper with recommendations for reducing disparities is online.
ACP members can get registration discounts for the eHealth Initiative's Health Information Technology Summit, to be held Sept. 7-9 in Washington. The College is a cosponsor of the annual meeting.
The conference will focus on state and federal information technology policy. Slated speakers include Michael Leavitt, HHS secretary, and internist David Brailer, MD, director of the HHS' Office of the National Coordinator of Health Information Technology.
Sessions will target integrating information technology into pay-for-performance strategies, navigating Medicare information technology policies, and the legal issues and strategies involved with health information sharing.
ACP members can register for the summit for $895--a $400 discount off the regular registration price of $1,295. When registering online, enter code "ehihit" to get the discounted rate.
More information is online.
Nursing homes may soon be required to provide flu and pneumonia shots to all their Medicare and Medicaid patients, under a proposed rule released last week.
The rule, published in the Aug. 15 Federal Register, would require all nursing homes to provide influenza and pneumococcal immunizations as a condition of participating in Medicare and Medicaid, according to an Aug. 11 CMS news release. Exceptions would be made if shots were refused by the patient or family, or contraindicated for medical reasons.
Nursing home residents are particularly at risk for contracting influenza and pneumonia, the release said. About 2 million elderly U.S. residents live in long-term care facilities and more than 90% of influenza-related deaths are among people age 65 and older.
The proposal is part of the CMS' focus on prevention, the release said. The goal is to attain a 90% rate for both vaccinations, compared with 1999 figures that showed only 65% of nursing home residents had received flu shots and only 38% had been immunized against pneumonia.
In January, the CMS increased the average Medicare payment for administering these shots from $8 to $18, said the release. The proposed rule has a shortened 15-day comment period to expedite the rule process before the flu season begins.
The proposal is on the Federal Register's Web site.
The CMS news release is online.
A national health insurer has started to post online the prices it pays for physician services, tests and procedures to allow health plan members to comparison shop for medical services.
Aetna Inc. launched the initiative last week for Cincinnati-area members, according to the Aug. 18 Wall Street Journal. The company is the first major insurer to disclose negotiated physician fees, a move the article said may influence other insurers and encourage the spread of consumer-driven health plans.
Consumers who enroll in plans that use health savings accounts draw from tax-free savings accounts to pay for health care services, up to a predetermined deductible, the Wall Street Journal reported. However, consumers typically get little or no information on what those services cost.
Under the Aetna plan, members can log onto Aetna's Web site to find the best price on any of 600 common services, such as physical exams or immunizations. Prices can vary from doctor to doctor, said Aetna officials, due to such factors as physician prestige, the supply of doctors in a given area or specialty, or practice size.
The new price transparency may put more pressure on physicians to compete, according to the article. While some will compete on price, others will try to attract patients by publicizing quality data or health plan ratings. The article also noted that if consumer-driven plans become more popular, health plans will be judged less on premiums and more on the quality of the information they provide to members.
The Wall Street Journal is online.
Applicants are now being sought for a one-year overseas fellowship in clinical research.
Medical students applying must have completed their basic science courses and one year of clinical clerkship. Fellows will collaborate in mentored research training at top-ranked NIH-funded research centers in a diverse group of countries, including Bangladesh, Brazil, China, Russia, Thailand and Zambia. The fellowships are sponsored by the NIH and managed by the Association of American Medical Colleges.
The one-year fellowship will begin in July 2006 with an intensive orientation program at the NIH in Bethesda, Md. In the past, more than two dozen fellows have been chosen to participate each year.
More information is online.
Fellowships available in health services
The CDC's National Center for Health Statistics (NCHS) is offering two fellowships to visiting scholars in health services research. Selected fellows will collaborate on studies of interest to policy-makers and to the health services research community.
Applications are being sought from doctoral students as well as from senior research and faculty. (Doctoral students must be at the dissertation phase of their programs.) Applicants must be U.S. citizens or permanent residents and must have training or experience in health services research and methodology, in disciplines such as public health or health care administration.
Each fellowship will last between 13 and 24 months. Fellows will use NCHS data systems and work at the NCHS facility in Hyattsville, Md.
The application deadline is Jan. 9, 2006.
More information is online.
The HHS is now seeking electronic public comments on proposed midcourse revisions to its Healthy People 2010 objectives.
Made public in 2000, Healthy People 2010 provides a set of 10-year evidence-based health objectives for improving the health of all Americans. Its two main goals are to increase the quality and years of healthy life, and to eliminate health care disparities. The program covers 28 focus areas with more than 460 specific objectives.
The proposed changes to the Healthy People 2010 objectives take the form of establishing or revising baselines and targets for some objectives, and changing the language of objectives or deleting other objectives. The proposed revisions are the result of a midcourse review, which assesses the status of the program's national objectives.
Public comments on the revisions will be accepted through Sept. 15, 2005. Healthy People 2010 is the HHS' third set of 10-year disease prevention and health promotions goals for the nation.
More information is online.
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Copyright 2005 by the American College of Physicians.
A 55-year-old man is evaluated during a follow-up visit for gout. Two years ago, he had been treated with allopurinol and developed a hypersensitivity reaction. Over the past several months, he has had recurrent attacks of acute, episodic swelling of the first metatarsophalangeal joints with increasing involvement of other joints, including the ankles and knees. Laboratory studies showed significant hyperuricemia. History is also significant for Crohn disease, hypertension, chronic kidney disease (estimated glomerular filtration rate of 55 mL/min/1.73 m2), and nonalcoholic fatty liver disease. Current medications are diltiazem and azathioprine, which he has been taking for the past 9 months. Which of these is a contraindication to the use of febuxostat in this patient?
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