American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News for the Week of 9-20-05

Disaster relief

Clinical news in the headlines

Health information technology

  • New study touts potential benefits of widespread EHR adoption
  • Medicare audioconference to feature ACP's EVP

Advocacy

Public health


Disaster relief

Many prescription records of Katrina victims now online

Records of prescriptions filled by hundreds of thousands of pre-Hurricane Katrina Gulf Coast residents have been posted online and are now available to physicians treating evacuees in shelters.

The federal government, which is coordinating the effort to develop a centralized health care record database, plans to add computerized medical records for Medicaid patients in Mississippi and Louisiana and pharmaceutical records from Veterans Affairs clinics and hospitals.

In the database so far are pharmacy records from CVS, Rite Aid, Albertsons, Walgreen and Wal-Mart. According to the Sept. 14 Washington Post, Winn-Dixie, Kmart and Target are about to add their computerized records from 150 zip codes in areas hit by Hurricane Katrina. The database now contains records of about 800,000 people.

This is the first time private health care records from competing pharmacies and health care providers have been compiled into one database. Although many privacy advocates have warned against such compilations, federal officials have said the effort could save lives, according to the Washington Post.

The original plan was for the emergency database to be temporary, ending when the evacuees were permanently resettled. Some involved with the effort, however, view it as a first step toward creating a standardized electronic health record for all Americans, the Washington Post said.

The Washington Post is online.

The CDC has also posted blank "Keep It With You" forms that can serve as a temporary medical record for both physicians and patients. While the form is not meant to replace permanent electronic or paper records, it does provide an interim tool for patients receiving temporary clinical services.

Physicians can download copies of the CDC form online.

Annals.org has posted a Hurricane Katrina resource page with updated information for physicians who want to help with hurricane relief efforts.

Annals editors have also created a Hurricane Katrina message board to allow physicians caring for hurricane victims and evacuees to post messages about their experience.

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Government will reimburse evacuees' health care costs in Texas

The federal government is stepping in to help Texas deal with added health care costs due to the influx of evacuees. About 373,000 evacuees from Gulf Coast states are now in Texas and many have no health insurance.

Under the first agreement of its kind, the federal government will waive normal documentation requirements for Medicaid and for the Children’s Health Insurance Program for hurricane evacuees in Texas, according to the Sept. 15 Houston Chronicle. It will also reimburse the state’s uncompensated care pool, which can be used by uninsured evacuees not eligible for Medicaid to visit doctors and hospitals and fill prescriptions.

According to CMS administrator Mark McClellan, FACP, coverage for both programs will be retroactive to Aug. 14 and will run through Jan. 31, 2006. Texas is the first state to reach such an agreement with the CMS, but Dr. McClellan said the program will be a model for other states coping with hurricane evacuees.

The Houston Chronicle is online.

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Jobs abound for displaced health care workers

Recruiters, hospitals and health care systems are swooping down on the Gulf Coast, offering jobs to physicians, nurses, physical therapists, radiation technicians and other health care workers displaced by Hurricane Katrina.

According to a report in the Sept. 16 USA Today, classifieds in Gulf Coast newspapers are filled with ads from doctors’ offices, clinics and hospitals across the country. Some are offering signing bonuses, relocation assistance or other perks to people willing to relocate. Some jobs being offered are temporary, but many are permanent.

Although the job opportunities are good news for physicians and nurses, according to USA Today, some in the area are questioning whether the recruitment drive may lead to extreme workforce shortages in health care facilities throughout Louisiana and Mississippi.

USA Today is online.

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Clinical news in the headlines

Highlights of Annals of Internal Medicine

The following articles appear in the Sept. 20 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.

  • Canadian drugs on Internet are cheaper than U.S. Internet drugs. A 2004 survey of drug prices of 44 retail brand-name medications advertised on 12 Canadian pharmacy Web sites and three large American pharmacy chains found that 41 of the 44 drugs were less expensive at Canadian pharmacies. The three drugs that cost more at Canadian pharmacies were for erectile dysfunction. Researchers estimate that Americans could save about 24% per dose if they bought prescription drugs from Canada.

  • Study finds second-generation antidepressants similar. Researchers comparing published studies of the efficacy, effectiveness, safety and side effects of second-generation antidepressants in treating depression did not find much difference among them, according to a new study. Response rates differed only minimally, researchers wrote, while "overall rates of adverse events and discontinuation of therapy were similar."

    Second-generation antidepressants include SSRIs, selected norepinephrine reuptake inhibitors and other drugs. Adverse effects differed but few studies used a standardized scale to measure them. Researchers concluded that it is difficult to choose the most appropriate antidepressant for a given patent.

  • Health program for musculoskeletal disorders reduces work disability. Study results from a program that treated musculoskeletal disorders in more than 13,000 patients with either regular care or a special health program found that the special program shortened temporary work disability and reduced the number of patients who went on permanent disability.

    Regular care included treatment by a primary care physician with referral to a specialist if needed. The targeted program included unlimited visits to a rheumatologist, patient education and free medications. While the special program was relatively expensive, the program by the end of the second year saved between $8 and $20 for every dollar invested and overall saved more than $5 million.

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Digital mammography works better than film for younger women

Study results published last week found that new digital mammography is more accurate than traditional film mammography when screening younger women and women with radiographically dense breasts for breast cancer.

The study of nearly 50,000 asymptomatic women who were screened at 22 different sites looked at five different digital mammography systems plus film mammography. Researchers found that 2.9% of the women had both positive digital and film mammograms, but 5.6% had positive digital mammograms only and 5.7% had positive film mammograms only. Findings were published in the Sept. 16 New England Journal of Medicine.

The histological findings and stage of cancer were similar when detected by either of the two methods, while the diagnostic accuracy of digital and film mammography was the same when results were analyzed according to a woman's race, risk of breast cancer or type of digital machine used.

However, diagnostic accuracy for digital mammography was significantly better among women younger than 50, those who were premenopausal and perimenopausal, and those with dense breast tissue.

The cancers detected, moreover, included “many invasive and high-grade in situ cases … precisely the lesions that must be detected early to save lives through screening,” the authors wrote. Neither digital nor film mammography detected all the breast cancers in the population.

Digital mammography costs about 1.5 to 4 times more than film systems and was developed in part to address some of the limitations of traditional film mammography. Only about 8% of mammograms currently are done digitally.

The full text of the NEJM article is online.

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New guidelines released on diagnosing metabolic syndrome

Revised guidelines released last week expanded the criteria used in diagnosing metabolic syndrome. If followed, the revisions would significantly increase the number of patients who could be diagnosed with the condition.

The guidelines were issued by the American Heart Association (AHA) and the National Heart, Lung and Blood Institute. The revisions expanded criteria for determining patients' risk to include:

  • lowering waist circumference thresholds when individuals or ethnic groups are prone to insulin resistance;

  • allowing triglycerides, HDL-C levels and blood pressure to be counted as abnormal when a person is already taking medication for these factors;

  • interpreting the definition of elevated blood pressure as one that exceeds the threshold for either systolic or diastolic pressure; and

  • reducing the threshold for counting elevated fasting glucose from equal to or greater than 110 mg/dL to equal to or greater than 100 mg/dL. This latter threshold is the American Diabetes Association's newly revised definition of impaired fasting glucose.

Patients can be diagnosed with the syndrome if they exhibit any three of five different metabolic risk factors. Those risk factors are atherogenic dyslipidemia; elevated blood pressure; elevated plasma glucose; a prothrombotic state, and a proinflammatory state.

According to a Sept. 13 AHA press release, patients with metabolic syndrome have as much as a three-fold increased risk for atherosclerotic cardiovascular disease and as much as a five-fold greater risk of type 2 diabetes. Guidelines were published in the Oct. 18 Circulation.

According to the Sept. 12 USA Today, however, expert groups don't agree on whether metabolic syndrome is an accurate diagnosis. Last month, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes said in a joint paper that metabolic syndrome is not well-defined. The “syndrome” is a combination of cardiovascular risk factors, the paper argued, not a unique disease. The paper appeared in the September Diabetes Care and Diabetologia.

Different groups include different risk factors, the ADA said, suggesting that there is no clear evidence for how to diagnose the syndrome. The authors recommended that physicians treat cardiovascular risk factors individually and not attempt to treat metabolic syndrome as a separate condition.

The Circulation executive summary is online.

The AHA release is online.

The USAToday article is online.

ObserverWeekly coverage of the ADA's position is online.

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Health information technology

New study touts potential benefits of widespread EHR adoption

A new and controversial study claims the United States could save as much as $162 billion a year and dramatically improve the quality of medical care if physicians, hospitals and other providers adopted electronic health record (EHR) systems.

RAND Corp. researchers reached those conclusions based on computer models designed to show what would happen if interoperable EHR systems were adopted widely and used effectively.

The study was published in the September/October issue of the health policy journal Health Affairs. However, commentaries published in the same issue took issue with the RAND findings, questioning whether savings of that magnitude are realistic. The published commentaries also took issue with the assumptions used in the RAND study.

The RAND study found that the cost of acquiring health information technology in physician offices is one of the principal barriers to widespread adoption, with EHRs costing on average $33,000 per physician for a practice to acquire the technology and $1,500 per physician per month to maintain.

One central argument by the RAND team is that the federal government will have to play a significant role in both financing the high cost of implementing EHRs and in setting interoperability standards.

The study also found, however, that the cost over 15 years of getting hospitals and doctor offices to adopt EHRs would be significantly less than the savings they would reap. RAND estimates the average yearly cost of EHR adoption would be about $7.6 billion, compared to $162 billion per year in possible savings. Savings would include:

Widespread adoption of computerized physician order entry in both ambulatory settings and hospitals that could eliminate many avoidable adverse drug events, saving about $4.5 billion a year.

EHR-based disease management programs for such chronic problems as asthma, congestive heart failure, chronic obstructive pulmonary disease and diabetes that could save “several tens of billions of dollars per year” in reduced hospitalizations and emergency room visits.

Better short-term preventive care, including screening exams and immunizations, buoyed by electronic record systems that could save between $100 and $400 million a year.

The Health Affairs abstract is online.

In related news, a new survey of group practices found a scant 11.5% of medical groups has a fully implemented EHR system for all physicians in all locations.

According to survey results released last week by the Medical Group Management Association (MGMA), another 12.7% of practices are in the process of implementing an EHR, while 14% say they plan to do so next year and nearly 20% say they intend to implement an EHR within the next two years.

However, more than 41% of the 3,300 practices surveyed earlier this year reported having no plans to go to electronic health records in the next two years. That number was highest among small groups, with nearly half (47.8%) of groups with five or fewer physicians saying they now have no plans to convert to EHRs.

Barriers cited include lack of support, lack of capital to invest, the fear of lost productivity, and no time for EHR selection and implementation.

MGMA survey results are online.

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Medicare audioconference to feature ACP's EVP

John Tooker, FACP, the College's EVP/CEO, will be a featured panelist in an upcoming audioconference on Medicare promotion of health information technology systems.

During the audioconference, to be held Sept. 27, Dr. Tooker will discuss challenges, opportunities and expectations for information technology adoption. He will also address how the promotion of information technology in health care will affect community technology initiatives and regional health information organizations.

Other conference faculty will discuss the complexities and barriers of information technology adoption and different policy and program initiatives being considered, including some of CMS's recently announced programs.

The conference will be held Sept. 27 from 1 p.m.-2:30 p.m. (EDT). Experts from both the federal government and the private sector will continue discussions on Health Affairs studies related to the economics of health information technology.

Audioconference registration is $345. For more information and registration, visit the National Medicare Audioconferences Web site.

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Advocacy

ACP Services strengthens the voice of internal medicine on Capitol Hill

With the 109th Congress poised to take action on several key health bills—including legislation to block pending cuts in the Medicare physician fee schedule—ACP and ACP Services Inc. have stepped up their advocacy efforts on Capitol Hill on issues such as unfair reimbursement rates, skyrocketing medical liability costs and the growing number of uninsured Americans. In addition, ACP Services Inc. established ACP Services PAC to complement its advocacy efforts on behalf of internists and their patients.

ACP Services PAC contributes to congressional candidates who serve on key health committees and whose voting records and positions are consistent with the specialty’s legislative priorities. Through its involvement in the political process, the PAC helps the specialty strengthen its voice on Capitol Hill and shape public policy to be more responsive to the needs of internists and their patients.

The ACP Services Board of Directors recently expanded the PAC board to include representation from the state of Texas and from young physicians. F. David Winter, FACP, from Dallas, and Shakaib U. Rehman, FACP, from Mt. Pleasant, S.C., were appointed for two-year terms that expire in July 2007.

The ACP Services Board of Directors also reappointed the following PAC Board Members for two-year terms: John F. DeCarli, FACP; Paul A. Gitman, FACP; Edward D. Harris Jr., FACP; and Richard L. Neubauer, FACP.

More information is online.

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Public health

Now available: minority health policy fellowships

Fellowship applications are now being accepted for the Commonwealth Fund/Harvard University fellowship in minority health policy 2006-07 program. Five fellowships will be awarded for the one-year program.

The deadline for filing an application is Jan. 3, 2006, while winners will be announced April 14. The fellowships are designed to prepare physicians—especially minority doctors—for leadership roles in devising and carrying out public health policy at the local, state, or national level. The fellowships are paid for by the Commonwealth Fund and administered by Harvard Medical School.

Applicants must be physicians who have completed residency, are U.S. citizens and plan to pursue a career in public health practice, policy or academia. Among other provisions, each fellowship comes with a $50,000 stipend, full tuition and health insurance.

Course work will be completed at Harvard's School of Public Health and will lead to a master's of public health degree (MPH). Those who already have an MPH can work toward a master's of public administration at Harvard's John F. Kennedy School of Government.

More information and a downloadable brochure are online.

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Copyright 2005 by the American College of Physicians.

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A 66-year-old man comes for a preoperative evaluation before total joint arthroplasty of the left knee. He has a 25-year history of rheumatoid arthritis. He has had progressive pain in his left knee with activity, which limits his ability to hike. The patient has similar pain in the right knee, but it is less severe. He reports no recent morning stiffness. He is able to climb two or three flights of stairs without chest pain or shortness of breath. He has no other medical problems and reports no additional symptoms. Medications are methotrexate and folic acid. Following a physical exam and lab tests, what is the next best step in management?

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