In the News for the Week of 9-27-05
- New Web site lets physicians access evacuees’ Rx records
- College endorses hurricane relief bill
- Free shelter living information sheet now available
- CMS selects 10 national insurers for new drug benefit
Clinical news in the headlines
- Older antipsychotic rivals costly newer drugs
- ACP Journal Club: Cardiac resynchronization reduced death and hospitalization
- U.S. spending on medical research soars to nearly $95 billion
A new Web site allows patients displaced by Hurricane Katrina and their physicians to access their prescription records online.
KatrinaHealth.org allows pharmacists and physicians to access medication histories and dosage information of storm evacuees whose paper records have been destroyed or lost. The site is aimed at helping patients refill needed medications and physicians avoid prescribing errors. It is supported by a consortium of government agencies, private businesses, nonprofit foundations and health care groups, including the College.
Once authorized to use the site, physicians can go online to access patient records from Louisiana and Mississippi Medicaid, commercial pharmacies, and pharmacy benefit managers. Any licensed U.S. physician or pharmacist can use the secure site after receiving a login and password by calling 800-262-3211. Physicians will be asked to verify their identities and credentials.
If evacuees' information is available on KatrinaHealth.org, physicians will be able to view their record, including medication quantity and day supply; the dispensing pharmacy; the prescribing physician; and any other drug information such as dosage or interactions. The information is “read only” and cannot be modified.
Web site developers are working to link information from other sources to provide a more complete database of evacuees' health records. Physicians are advised that the data may not be current or may contain duplications or omissions as they have been culled from a variety of sources.
KatrinaHealth information for physicians is available online.
Annals has posted a Hurricane Katrina resource page with updated information for physicians who want to help with relief efforts.
The College has issued a strong endorsement of legislation that would help people displaced by Hurricane Katrina maintain their access to health care.
In Sept. 16 letters to Sens. Max Baucus (D-Mont.) and Charles E. Grassley (R-Iowa), the College expressed support for the Emergency Health Care Relief Act of 2005 (S. 1716), which eases current Medicaid restrictions and eligibility requirements for hurricane survivors from Louisiana, Mississippi and some counties in Alabama.
The legislation also establishes a disaster relief fund, allowing providers to qualify for federal assistance if they can show a significant increase in services provided to Medicaid beneficiaries or a rise in their amount of uncompensated care.
The legislation would extend Medicaid coverage to all adult Katrina survivors with incomes at or below 100% of the federal poverty limit and to surviving children and pregnant women at 200% of that limit. It would also simplify the enrollment process and provide coverage to those living outside the disaster area who lost their jobs as a result of the storm.
The letter, which was signed by College President C. Anderson Hedberg, FACP, supports waiving Medicare Part B late enrollment penalties for those affected by the storm. Dr. Hedberg noted that the College is awaiting an October report from the government to find out how the CMS will shift dual-eligibles to the new Medicare prescription drug plan, which begins in January.
The College’s letter is online.
To overcome some of the challenges facing people living in shelters due to recent storms, ACP Foundation now offers "HEALTH TiPS for Healthy Shelter Living," a patient information sheet on important health issues, such as the need for handwashing and the risks involved in sharing medicine.
ACP Foundation, working with health literacy experts and physicians, created the one-page handout for volunteers to use with shelter residents. HEALTH TiPS for Healthy Shelter Living is written at a third-grade reading level, is available in English and Spanish, and is available in plain text or with illustrations.
ACP members can also order other HEALTH TiPS pads on pain and hypertension online.
The CMS last week announced that it has granted approval to 10 insurers to provide nationwide drug coverage when the new Medicare drug benefit begins in January.
In addition to the 10 national insurers, many other insurers are approved to provide coverage regionally, according to the Sept. 23 Washington Post. As a result, beneficiaries will have between 11 and 20 plans to choose from depending on where they live.
Staunch competition among insurers has resulted in lower prices for beneficiaries, the article said. Beneficiaries in 49 states will be able to sign up for a drug plan with a monthly premium of less than $20.
According to the Washington Post, the 10 national insurers are Aetna Life Insurance Co., Connecticut General Life Insurance Co., Coventry Health and Life Insurance, Medco, Memberhealth Inc., Pacificare Life and Health Insurance Co., Silverscript Insurance Co., Unicare, United Health Care Insurance Co. and Wellcare Health Plans.
Marketing of the plans begins Oct. 1 while beneficiaries can begin enrolling on Nov. 15. The Washington Post noted that CMS administrator Mark McClellan, FACP, had rejected calls to delay the program launch because of Hurricane Katrina and recovery effort costs.
The Washington Post is online.
For more information, see "Getting yourself ready for Medicare Rx" in the October ACP Observer.
Clinical news in the headlines
An older antipsychotic drug performed as well as newer, more expensive atypical antipsychotics in a study of patients with schizophrenia.
The little-used perphenazine, which came on the market in the 1950s, proved as effective as any atypical agent except olanzapine (Eli Lilly’s Zyprexa), according to the Sept. 20 Philadelphia Inquirer. While patients taking olanzapine were less likely to stop using this medication due to side effects or poor symptom control, said the article, they were also more likely to gain weight.
The study included 1,493 patients with schizophrenia who were randomly assigned to receive daily doses of either olanzapine (7.5 mg-30 mg), perphenazine (8 mg-32 mg), quetiapine (200 mg-800 mg), risperidone (1.5 mg-6 mg) or ziprasidone (40 mg-160 mg) for up to 18 months. Almost three-quarters of patients discontinued their medication before the end of the study period, with the fewest people discontinuing olanzapine (64%). The study appears in the Sept. 22 New England Journal of Medicine (NEJM).
The effectiveness of perphenazine is noteworthy, the Philadelphia Inquirer said, because the older drug costs considerably less than newer atypical antipsychotics: $50 a month vs. more than $600 a month for olanzapine. The authors noted that atypical antipsychotics are widely used and have a 90% market share in the United States.
The newer generation of antipsychotics became popular because they were less likely to induce neurological side effects, the authors said. However, the low doses of perphenazine used in this study reduced those side effects and there was no significant difference in extrapyramidal symptoms between patients receiving first-generation and second-generation drugs.
All the medications have limited effectiveness due to the high rate of discontinuation, said the authors. They noted that while olanzapine was the most effective of the five, it also posed a safety risk due to its association with greater weight gain and increases in glycosylated hemoglobin, cholesterol and triglycerides.
The NEJM abstract is online.
The Philadelphia Inquirer is online.
See also “New advisory on antipsychotic drugs may limit care options” in the July/August ACP Observer.
A new study on cardiac resynchronization concluded that the technology can significantly reduce death and hospitalization in certain patients with heart failure.
The 29-month trial included 813 adults with moderate-to-severe medically refractory heart failure who had been receiving standard pharmacologic therapy for six weeks or more. Patients who received medical therapy plus cardiac resynchronization had a 20% all-cause mortality rate vs. 30% for those receiving usual care (a 32% relative risk reduction). In addition, cardiac resynchronization patients had a 28% relative risk reduction in unplanned hospitalizations.
The study is abstracted in the September-October ACP Journal Club.
This study should answer any remaining doubts about the efficacy of cardiac resynchronization therapy for moderate-to-severe medically refractory heart failure, said Journal Club reviewer Carlos A. Morillo, MD, who's with McMaster University-Hamilton Health Sciences in Hamilton, Ontario, Canada. While recent studies have shown that cardiac resynchronization is effective in preventing hospitalization and disease progression, he said, this trial goes further by demonstrating that cardiac resynchronization can help reduce mortality.
The trial also highlights the effectiveness of echocardiographic markers of cardiac dyssynchrony, which may have played a role in the study results by selecting responders to cardiac resynchronization, the reviewer said. Current ongoing trials may provide answers on whether implantable-cardioverter therapy alone or combined with cardiac resynchronization will further reduce mortality.
Peer ratings for this article: Hospitalists rated it 7 out of 7, while cardiologists rated it 6 out of 7.
ACP Journal Club is online.
The nation’s spending on medical research more than doubled over the past decade, according to a new study that said vigilance is needed to ensure that funding goes to areas of greatest clinical need.
Biomedical research funding increased from $37.1 billion in 1994 to $94.3 billion in 2003 (doubled when adjusted for inflation), representing 5.6% of the nation’s total health expenditures, according to the study in the Sept. 21 Journal of the American Medical Association (JAMA). Spending on clinical trials by industry increased from $4 billion to $14.2 billion over the same period. Meanwhile, only 0.1% of total U.S. health expenditures went to health services research.
The study portrays a health care system that is driven more by the profit potential of existing drugs than by translating basic research into new clinical applications, according to the Sept. 20 Los Angeles Times. The focus on late-stage research is due both to a lengthier drug approval process, the article said, and a tendency by drug companies to spend more on studies that compare their drugs with those of competitors.
The study noted that pharmaceutical productivity has declined from 24 new drugs and devices receiving FDA approval in 1998 to 11 approved in 2004. The decline highlights the need, said the authors, for investment in clinical areas that have few effective treatments and for which new classes of drugs are possible.
The JAMA abstract is online.
The Los Angeles Times is online.
The CMS is inviting physicians to try out Vista Office, its ambulatory electronic health record (EHR) technology adapted from the hospital-based system used by the VA.
An evaluation version of Vista Office is available from qualified vendors listed on CMS’ Vista Web site, according to a Sept. 19 CMS news release. Physicians interested in participating should also visit the evaluation site.
The initial version will be assessed for how well it shares data and communicates with other systems, which is known as interoperability; its performance in a physician office setting; and its ability to maintain privacy and security, said the CMS release. Based on physician feedback, software vendors will develop a final version of Vista Office that will be certified by the HHS.
Vista Office functions include order entry, documentation templates, clinical reminders and the ability to fax prescriptions, the release said. It also incorporates functions relevant to participation in pay-for-performance programs, such as patient registries and measurement reporting.
Physicians should expect to pay a small fee for acquiring the software on disk as well as licensing and support fees, the release said. In addition, implementation typically requires added staff time and vendor support for installation, configuration and maintenance. The CMS is helping train vendors though WorldVista, a vendor support organization, and will evaluate vendor services before the final version is released.
A CMS news release is online.
More information from CMS is available online.
For more information, see "Vista EHR: right product, right price?" in the September ACP Observer.
Electronic health records (EHRs) are starting to catch on in large practices but solo and small practices—where most physicians work—lag far behind, according to study results released last week.
Almost 18% of physicians included in the ambulatory medical care survey from the National Center for Health Statistics, an arm of the CDC, reported using EHRs between 2001 and 2003, according to the Sept. 21 Modern Physician. Of those, only 13% were in solo practice and slightly more than 16% were in practices with only two to four physicians. The study appears in the September/October Health Affairs.
The survey found that EHR use increased with practice size. In practices of between 10 and 19 doctors, 28% used EHRs while usage was 40% in practices with 20 or more physicians, Modern Physician reported. Three-quarters of the 3,360 physicians surveyed were in practices of between one and four doctors while less than 10% were in practices with 10 or more physicians.
EHR use was also more common in practices owned by HMOs, where 53% of doctors surveyed reported using EHRs compared with 16% among physician-owned practices, said Modern Physician. The authors noted that the majority of physicians surveyed (86%) worked in physician-owned practices while less than 2% worked in HMO groups.
The authors concluded that the likelihood of a practice adopting EHRs is related far more to practice size than to other factors such as characteristics of individual physicians, scope of services or sources of revenue.
The Health Affairs abstract is online.
Modern Physician is online.
The College has joined a diverse group of stakeholders in signing onto an amicus brief that supports a patient's right to quality language services in health care.
The brief supports a lawsuit challenging HHS policy on providing language services to non-English speaking patients. The suit, originally filed in 2004, was brought by several organizations including the Association of American Physicians and Surgeons, a national association that supports free market principles in medical practice. A federal district court dismissed the suit earlier this year and that decision is now being appealed.
The lawsuit was filed after President Clinton's administration determined that a requirement under Title VI of the Civil Rights Act was not being interpreted properly. This provision said that any recipient of federal funding cannot discriminate on the basis of language. But it was the interpretation of how the providers should meet the law's obligations that prompted the lawsuit.
The plaintiffs argue that HHS's interpretation of the law would make them hire interpreters and that the HHS would enforce its interpretation. This requirement, they contend, would create an economic burden that would interfere with the physician-patient relationship.
The federal district court that dismissed the suit claimed HHS interpreted existing regulatory authority, imposed no new obligations and resulted in no specific enforcement actions against the plaintiffs.
ACP signed the amicus brief—which has more than 60 signatories--because the brief is based in part on a statement of principles that ACP helped draft in 2004. Among other provisions, those principles state that effective communication between physicians and patients is essential, and that federal, state and local governments—as well as insurers—should establish and fund mechanisms for appropriate language services.
According to ACP policy adopted in 2003, physicians should not be responsible for arranging or paying for language services. The amicus brief does not argue the merits of the law or its interpretation, nor get into specifics of who should be responsible for ensuring quality language services.
Furthermore, the brief emphasizes the need for quality communication and language services, discusses the ramifications of not providing language services, and states that the burden of providing language services in health care should be a "societal one."
ACP is not financially supporting the lawsuit.
The brief, including the language access statement of principles, is online.
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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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